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DISEASES    V 


OF 


IIFANTS  AND  CHILDREN 


BY 
HENRY  DWIGHT  CHAPIN,  A.  M.,  M.  D. 

PROFESSOR   OF   DISEASES   OP   CHILDREN,  NEW  YORK  POST-GRADUATE  MSt)ICAL  SCHOOL  AND  HOSPITAL; 

SUPERVISING    PHYSICIAN    OF    THE   CHILDREN'S    DEPARTMENT,  NEW  YORK    POST-GRADUATE 

hospital;    ATTENDING    PHYSICIAN    AT    THE  WILLARD    PARKER    AND  RIVERSIDE 

hospitals;  consulting  physician  to  the  Randall's  island 
hospital  and  to  st.  agnes  hospital,  white  plains 

AND 

GODFREY  ROGER  PISEK,  M.  D. 

PROFESSOR  OF  DISEASES  OF  CHILDREN,  UNIVERSITY    OF   VERMONT;   ADJUNCT   PROFESSOR   OF  DISEASES 

OF  CHILDREN  AND  ATTENDING  PHYSICIAN  TO  THE  NEW  YORK  POST-GRADUATE  MEDICAL  SCHOOL 

AND    hospital;   attending    physician    TO    THE    DARRACH    HOME    FOR    CHILDREN 

ROBERT  D  f'  '  ORA  B.  EMERY 


WITH  179  ILLUSTKATIONS . 
A^B  ELEVEN  COLORED  PLATES 


NEW  YORK 

WILLIAM  WOOD  AND  COMPANY 

MDCCCCIX 


vysaoo 


Copyright,  1909, 
By  WILLIAM  WOOD  AND  COMPANY. 


Printed  by 

The  Maple  Prea 

York,  Pa. 


HOBER 


'  "  ^'  ""'  e.  EMEfl' 


TO 

THE  STUDENTS 

BOTH  GRADUATE  AND  UNDERGRADUATE 

IN  THE 

UNITED  STATES  AND  CANADA 

WHOM  IT  HAS  BEEN  OUR  PLEASURE  TO  TEACH 

THIS 

BOOK  IS  DEDICATED. 


D 


PREFACE.     >f^- 


This  volume  has  been  written  by  teachers  who  feel  tnw  a^large 
contact  with  students  has  made  them  fairly  familiar  with  their  ctej^. 
Probably  the  first  requirement  at  present  is  to  bring  each  branch  of^ 
medicine  into  as  compact  a  form  as  is  consistent  with  a  thorough      V^a^ 
presentation  of  the  subject.     Our  aim  has  been  to  accomplish  this  V 

with  pediatrics.  To  many,  the  diagnosis  and  treatment  of  diseases 
of  infants  and  children  are  most  perplexing.  These  difficulties  can 
only  be  overcome  by  first  sharply  differentiating  the  anatomical  and 
physiological  peculiarities  of  the  infant  and  child,  and  then  consider- 
ing their  practical  bearings. 

The  student  must  be  familiarized  with  all  the  more  recent  tests, 
as  well  as  the  older  practical  bedside  experience,  in  the  study  of 
disease.  He  will  then,  by  a  systematic  examination  of  the  patient, 
be  able  to  make  a  scientific  diagnosis.  He  must  also  be  taught  to 
treat  rationally  and  with  a  distinct  purpose  in  mind.  We  have  aimed 
to  present  the  subject  in  this  way,  and  thus  to  make  the  work  as 
practical  as  possible.  The  physician  needs  such  a  description  of 
disease  as  he  will  actually  encounter  at  the  bedside.  Where  pictures 
can  serve  as  a  type,  we  have  used  illustrations,  most  of  which  are 
original.  Theory  and  pathology  have  only  been  considered  in  so  far 
as  may  be  necessary  to  an  understanding  of  the  diagnosis,  course  and 
treatment  of  disease.  We  have  tried  to  take  a  middle  course  between 
the  compendium,  w^hich  is  usually  unsatisfactory,  and  a  too  exhaust- 
ive work,  which,  by  dwelling  overmuch  on  theory  and  exceptions, 
tends  to  confuse  the  reader. 

Our  thanks  are  due  to  our  hospital  assistants,  Drs.  Dennett  and 
Albee,  for  their  help  during  the  progress  of  the  work.  While  a  book 
of  this  sort  must  be  indebted  to  all  the  workers  in  pediatrics,  whom 
we  have  freely  consulted,  our  personal  experience  at  the  Infants'  and 
Children's  Wards  of  the  New  York  Post-Graduate  Hospital,  and  in 
private  practice,  has  formed  the  essential  basis  of  our  description  of 
the  diseases  and  their  treatment. 

Our  thanks  are  due  to  the  publishers  for  their  care  and  courtesy 
in  the  preparation  of  the  book. 

The  Authors. 

New  York,  September,  1909. 


24633 


CONTENTS. 

SECTION  I. 
The  Neavly-born. 


CHAPTER  I. 

Page 

The  Management  and  Care  of  Premature  Infants      1 

CHAPTER  II.            ^ 
Injuries  During  Birth.    Gf^ 
Deformities  of  Head;  Caput   Succedaneum;   Cephalhem^Ana ;   Injuries  to 
Bone  and  Muscle;  Birth  Palsies;  Facial  Paralysis;  Upp^-arm  Paralysis 
(Duchennes);    Central    Paralysis;    Asphyxia;    Congenita  Atelectasis; 
Fetal  Death '.^ 6 

CHAPTER  III.                                </p^ 
Diseases  of  the  Newly-born.                     -^ 
Acute  Infectious  Diseases;   Sepsis  of    the   Newly-born;   Umbilical   Hemor- 
rhage; Umbilical   Vegetations;  Umbilical  Hernia;  Epidemic  HemogLi^ 
binuria    (Winckel's    Disease) ;  Fatty  Degeneration   of  the   Newly-boi'wJ,^ 
(Buhl's  Disease);  Icterus  Neonatorum;  Tetanus  Neonatorum;  Conjunc- ««^ 
tivitis;  Ophthalmia  Neonatorum;  Mastitis;  Spontaneous  Hemorrhages     ^ 
in  the  Newly-born 14 

SECTION  II. 
Hygiene  of  Infancy. 


CH.\PTER  IV. 

Hygiene  of  Infancy. 

Clothing;  The  Nursery;  Bathing;  Exercise  and  Fresh  Air;  General  Habits.  .      25 

CHAPTER  V. 

Weight  and  Development. 

Weight;   Length;   General   Shape;   Head;    Brain;  Spine;   Glands;  Stomach; 

Intestines  and  Liver;  Bladder;  Muscles;  Dentition;  Delaj'ed  Dentition; 

Disturbances  of  Dentition;  Care  of  Temporary  Teeth;  Permanent  Teeth; 

Hutchinson's    Teeth;    Growth    during    Childhood;    Mental    and    Moral 

Growth;  Adolescence 28 

vii 


Vlll  CONTENTS. 

SECTION  III. 

The  Examination  of  the  Sick  Child. 


CHAPTER  VI. 

The  Examination  of  the  Sick  Child. 

Page 
History;    Inspection;    Palpation;    Auscultation;    Percussion;    Mensuration; 

Rectal  Examination 41 

CHAPTER  VII. 

Special  Examinations. 
Lumbar  Puncture;  Estimation   of    Hemoglobin;  Test   for    Indican;  Trans- 
udates and  Exudates;  Aspiration  of  Pleural  Cavity ;Tuberculin  Tests; 
Thread  Reaction  in  Pyelitis ;  Wasserman  Test  for  Syphilis       51 

CHAPTER  VIII. 

Signs  of  Illness  in  Infancy. 
Irritability  of  Temper;  Restless  Sleep;  Changes   in  Features;  State  of  the 

Discharges      57 

CHAPTER  IX. 

General  Therapeutics. 
Drug    Administration;    Table    of    Average    Doses;    Introductory    Remarks; 
Psychotherapy;    Aerotherapy;    Hydrotherapy;    Nasopharyngeal  Toilet; 
Lavage;    Enteroclysis;    Gavage;    Rectal    Feeding;     Vaccine    Therapy; 
Exercises 60 

CHAPTER  X. 

Suggestive  Scheme  for  Diagnosis. 
Head;  Neck;  Face;  Mouth;  Swallowing;  AbnormaUties  in  Breathing;  Chest; 
Abdomen;  Inguinal  Region;  Delayed  Growth;  Hemorrhages;  Extrem- 
ities            81 

SECTION  IV. 

Infant-Feeding. 


CHAPTER  XI. 
The  Infant  from  the  Nutritional  Standpoint. 
The  Infant;  Life  Divided  into  two  Nutritive  Periods;  Essential  Unity  of 
Foods;  Foods  of  the  First  Nutritive  Period;  The  Infant  a  Mammary 
Fetus;  Breast  Secretions;  Specialized  Foods;  Composition  and  Properties 
of  Breast  Secretions;  Comparative  Anatomy  and  Physiology  of  Digestive 
Organs;    Comparative  Mammary  Secretions;  Chemical  and  Biological 
Standards. 89 


CONTENTS.  IX 

CHAPTER  XII. 

Breast-feeding. 

Page 
Importance  of;  Preparation  for  Maternal  Feeding;  Management;  Regularity; 
Milk  Agrees;  Flow  Scanty;  Elimination  of  Drugs  and  Excretory  Products 
in  Milk;  Milk  Plentiful  but  Disagrees  with  Infant;  Examination  of  Breast 
Milk;  Nursing  not  Possible;  Contraindications  for  Nursing;  Weaning  and 
Mixed  Feeding;  Selection  of  Wet  Nurse 100 

CHAPTER  XIII. 
Principles  of  Substitute  Feeding. 
Difficulties  Encountered;  Principles  that  Apply  to  All  Infants;  Many  Forms 

of  Proteins,  Fats  and  Carbohydrates 110 

CHAPTER  XIV. 

Materials  Used  in  Substitute  Feeding. 
Cow's  Milk:  One  Cow's  Milk;  Influence  of  Breed  on  Composition;  Bacteri- 
ology of;  Production  of  Sanitary  Milk;  Market  Milk;  Pasteurized  and 
Sterilized  Milk;  Composition  of  Market  Milkj^ream;  Condensed  Milk; 
Evaporated  Milk.  Cereals:  General  Proper^^^  of  Carbohydrates  of 
Cereals.  Eggs:  Proprietary  Infant  Foods;  Classif(S^ion  of;  Analyses  of  .     113 

^> 

CHAPTER  XV. 

o 

Rise  and  Development  of  Scientific  InfantJ'eeding. 
Historical;  Fundamental  Errors  Made;  Classification  of  Method^ of  Modifying 
Milk;  Laboratory  Demonstrations  to  Illustrate  Effects  o^^^ethods  of 
Modifying  Milk;  Infants  tend  to  adapt  themselves  to  their  F'oM;  Infants 
differ  in  digestion  and  assimilation  efficiency;  Assimilation  most^fficient 
in  Early  Infancy 126 

CHAPTER  XVI.  %. 

<V% 
Practical  Feeding.  "VV. 

Basis  of;  Percentage  Milk  Mixtures;  Top  Milk;  Percentage  Cereal  Gruels; 
Composition  of  Milk  and  Gruel  Mixtures;  Outline  of  Feeding  Directions; 
Food  for  Healthy  Infants;  Directions  for  Making  Gruels;  Adaptation  of 
Food  to  Infant;  Food  for  Infants  Previously  Badly  Fed;  Feeding  History; 
Management;  Food  for  Infants  of  Feeble  Constitution;  A  Wet  Nurse 
Unobtainable;  Food  for  the  Acutely  111;  Management  of  Cases  when  All 
Attempts  at  Adding  Fresh  Milk  Fail;  Laboratory  Feeding;  Calorie 
Feeding;  Directions  for  Mother  and  Nurse;  How  to  Interpret  Results; 
Feeding  in  Hot  Weather;  Feeding  when  Traveling;  Feeding  when  Away 
from  Home;  Feeding  Among  the  Poor;  Infant's  Food  Dispensaries; 
Making  Feedings  on  a  Large  Scale;  Making  Food  at  the  Feeding  Stations .    136 

CHAPTER  XVII. 
Diet  During  the  Second  Ye.\r. 
Dietary  Twelfth  to  Eighteenth  Months;  Eighteenth  to  Twenty-fourth  Months; 
Two  to  Three  Years;  Diet  List  for  Children's  Hospitals;  Diet  Lists  for 
Day  Nurseries  and  Creches;  Diet  During  Later  Childhood 174 


CONTENTS. 

SECTION  V. 
Diseases  of  the  Digestive  System. 


CHAPTER  XVIII. 

Diseases  of  the  Mouth. 

Page 
General  Considerations;  Desquamative  Glossitis;  Simple  Stomatitis;  Aphthous 
Stomatitis;  Bednar's  Aphthae;  Perleche;  Mycotic  Stomatitis  (Thrush); 
Ulcerous  Stomatitis;  Gangrenous  Stomatitis  (Noma) ;  Elongated  Uvula  .     ISl 

CH.APTER  XIX. 
Diseases  of  the  Digestive  Tract. 

Corrosive  Esophagitis;  Congenital  Occlusion  of  the  Esophagus;  Acute 
Gastric  Indigestion  (Acute  Gastritis);  Chronic  Gastritis;  Dilatation  of 
the  Stomach;  Stenosis  of  the  Pyloris  and  Pyloric  Spasm;  Recurrent  or 
Cyclic  Vomiting;  Infant's  Stools;  Colic;  Acute  Gastroenteritis;  Acute 
Enterocolitis;  Chronic  Gastrointestinal  Indigestion;  Congenital 
Dilatation  of  the  Colon  (Hirschprung's  Disease);  Cholera  Infantum; 
Constipation       189 

CHAPTER  XX. 
The  Animal  Parasites. 

Parasitic    Protozoa;     Oxyuris    Vermicularis;    Ascaris    Lumbricoides;  Tenia 

Mediocanellata :  Tenia  Solium;  Uncinaria  Duodenalis;  Trichina  Spiralis.  211 

CHAPTER  XXI. 
Diseases  of  the  Liver. 

The  Liver;  Examination  of  the  Liver;  Jaundice;  Inflammation  of  the  Biliary 
Ducts;  Inflammation  of  the  Portal  Vein;  Congestion  of  the  Liver;  Fatty 
Liver;  Amyloid  Liver;  Cirrhosis  of  the  Liver;  Abscess  of  the  Liver  .    .    .     219 

SECTION  VI. 
The  Infectious  Diseases. 


CHAPTER  XXII. 
The  Infectious  Diseases. 

Measles;  German  Measles;  Scarlet  Fever;  Variola;  Vaccination;  Varicella; 
Tal)le  of  Exanthemata;  Diphtheria;  Pertussis;  Mumps;  Typhoid  Fever; 
Influenza;  Syphilis;  Cerebrospinal  Meningitis;  Anterior  Poliomyelitis; 
Epidemic  Paralysis  in  Children;  Acute  Articular  Rheumatism;  Chronic 
Articular  Rheumatism;  Malaria  (Paludism)  Erysipelas 22.5 


CONTENTS.  XI 

CHAPTER  XXIII. 

Page 

Disinfectants;  Disinfection 312 

CHAPTER  XXIV. 

Tuberculosis. 

Etiology;  Tuberculous  Adenitis;  Thoracic  Tuberculosis  in  Children;  Pul- 
monary Tuberculosis  (Acute  and  Chronic);  Acute  Miliary  Tuberculosis; 
Tuberculous  Meningitis;  Tuberculous  Peritonitis;  Tuberculosis  of  Bones 
and  Joints;  Tuberculosis  of  the  Vertebrae;  Tuberculous  Disease  of  the 
Hip;  Tuberculous  Disease  of  the  Knee;  Treatment  of  Tuberculosis  in 
General 316 


SECTION  VII. 
Diseases  of  the  Respiratory  Tract. 


CHAPTER  XXV. 

Diseases  of  the  Upper  Respiratory  Tract. 

Acute  Rhinitis;  Epistaxis;  Foreign  Bodies  in  the  Nose;  Examination  of  the 
Infant's  Throat;  Pharyngitis  and  Tonsillitis  in  Infants;  Acute  Pharyngi- 
tis; Acute  Follicular  Tonsillitis;  Ulcero-membranous  Tonsillitis  (Vincent's 
Angina) ;  Chronic  Tonsillar  Hypertrophy;  Adenoids;  Peritonsillar  Abscess; 
Retropharyngeal  Abscess;  Acute  Laryngitis  (Spasmodic  Croup);  Edema 
of  the  Glottis;  Laryngismus  Stridulus;  Congenital  Laryngeal  Stridor; 
New  Growths  in  Larynx 341 

CHAPTER  XXVI. 

Diseases  of  the  Lungs  and  Pleura. 

Acute  Bronchitis;  Chronic  Bronchitis;  Pulmonary  Collapse;  Emphysema; 
Bronchial  Asthma;  Acute  Bronchopneumonia;  Hypostatic  Pneumonia; 
Lobar  Pneumonia;  Pleurisy,  Dry,  Serofibrinous;  Empyema;  Pneu- 
mothorax; Pulmonary  Abscess;  Gangrene  of  the  Lung;  Bronchiectasis; 
Foreign  Bodies  in  the  Respiratory  Tract;  Subphrenic  Abscess 359 


SECTION  VIII. 
Diseases  of  the  Circulatory  System. 


CHAPTER  XXVII. 

Diseases  of  the  Heart. 

The    Heart;    Congenital    Heart    Disease    (Cyanosis);    Endocarditis;    Septic 

Endocarditis   Myocarditis 382 


Xll  CONTENTS. 

CHAPTER  XXVIII. 

Chronic  Valvular  Disease. 

Page 
Mitral  Regurgitation;  Mitral  Obstruction;  Aortic  Obstruction;  Aortic  Regur- 
gitation; Tricuspid  Regurgitation;  Functional  Cardiac  Disorders  .    .    .    .     389 

CHAPTER  XXIX. 

Diseases  of  the  Pericardium 395 

SECTION  IX. 
Diseases  of  the  Blood  and  Ductless  Glands. 


CHAPTER  XXX. 

Diseases  of  the  Blood. 

Glossary;  The  Blood;  Anemia;  Simple  or  Secondary  Anemia;  Chlorosis; 
Pernicious  Anemia;  Leukemia ;  Pseudo-leukemia  of  Infants  (von  Jaksch's 
Anemia);  Table  of  Anemias;  Treatment  of  the  Anemias;  Purpura; 
Purpura  Simplex;  Purpura  Hemorrhagica;  Henoch's  Purpura;  Schonlein's 
Purpura;  Hemophilia 398 

CHAPTER  XXXI. 

Diseases  of  the  Ductless  Glands. 

The  Thymus;  Enlargement  of  the  Thymus;  Status  Lymphaticus;  Diseases 
of  the  Spleen;  Inflammation  of  the  Spleen;  Chronic  Passive  Congestion  of 
the  Spleen;  Disorders  of  the  Adrenals;  Addison's  Disease;  Hodgkin's 
Disease  (Lymphadenoma) ;  Acute  Adenitis;  Chronic  Adenitis;  Exophthal- 
mic Goiter;  Achondroplasia;  Infantilism;  Cretinism     414 

SECTION  X. 
General  Diseases  of  Nutrition. 


CHAPTER  XXXII. 

Nutritional  Disorders. 
Rachitis;  Congenital  Rachitis;  Scorbutus;  Marasmus;  Diabetes  Mellitus  .    .     431 

SECTION  XI. 

Diseases  of  the  Uropoietic  System. 


CHAPTER  XXXIII. 

Diseases  op  the  Urine  and  Kidneys. 

The  Urine  in  Infancy;  Character  of  the  Urine;  Formation  of  the  Kidney; 
Anuria;  Polyuria;  Diabetes  Insipidus;  Renal  Calculi;  Hematuria;  Hemo- 


CONTENTS.  Xlll 

Pagk 
globinuria;  Functional  Albuminuria  (Cyclic  or  Physiologic  Albuminuria); 
Indicanuria;  Acetonuria  and  Diacetonuria ;  Congestion  of  the  Kidney; 
Chronic  Congestion  (Passive  Hyperemia)  of  Kidney;  Nephritis,  Acute, 
Chronic;  Pyelitis;  Perinephritis;  Tumors  of  the  Kidney;  Hydronephrosis; 
Enuresis  445 


SECTION  XII. 
Diseases  of  the  Genital  Organs  and  Bladder. 


CHAPTER  XXXIV. 

Diseases  of  the  Genital  Organs. 

Phimosis  and  Paraphimosis;  Balanitis;  Urethritis;  Vulvovaginitis,  Mastur- 
bation; Hydrocele;  Undescended  Testicle;  Differential  Diagnosis  of 
Swellings  in  the  Inguinal  Region '  .    .    472 

CH.^PTER  XXXV. 

Diseases  of  the  Bladder. 
Cystitis;  Vesical  Spasm;  Vesical  Calculus 480 

SECTION  XIII. 
Diseases  of  the  Nervous  System. 


CHAPTER  XXXVI. 

General  Nervous  Diseases. 

General  Considerations;  Paralysis  in  General;  Characteristics  of  the  Various 
Types;  Convulsions;  Chorea;  Hysteria;  Epilepsy;  Headaches  (Migraine); 
Insomnia;  Pavor  Nocturnus;  Tetany;  Congenital  Myotonia  (Thomson's 
Disease) ;  Paramyoclonus  Multiplex;  Angioneurotic  Edema;  Tics  .    .    .    .    482 

CHAPTER  XXXVII. 

Diseases  of  the  Peripheral  Nerves. 
Multiple  Neuritis;  Diphtheritic  Paralysis;  Facial  Paralysis 503 

CHAPTER  XXXVIII. 

Diseases  of  the  Spinal  Cord. 

Myelitis;  Multiple  Sclerosis;  Hereditary  Ataxia  (Friedrich's  Disease);  Primary 

Myopathies 507 


XIV  CONTENTS. 

CHAPTER  XXXIX. 

Diseases  of  the  Brain. 

Page 
Meningitis;  Encephalitis;  Abscess  of  the  Brain;  Tumors  of  the  Brain;  Cerebral 
Palsies;     Hydrocephalus;     Microcephalus;     Idiocy;    Imbecility;   Feeble- 
mindedness; Mongolian  Idiocy;  Amaurotic  Family  Idiocy       518 


SECTION  XIV. 
Congenital  Malformations  and  Deformities. 


CHAPTER  XL. 

Congenital  Malformations  and  Deformities. 

Tongue  Tie,  Hare-lip;  Cleft-palate;  Branchial  Cysts;  Malformations  of  the 
Esophagus;  Malformations  of  the  Rectum  and  Anus;  Hypospadias; 
Extrophy  of  the  Bladder;  Congenital  Dislocation  of  the  Hip;  Congenital 
Absence  of  Bones;  Talipes;  Webbed  Fingers  and  Toes;  Meningocele  and 
Encephalocele;  Spina  Bifida 535 


SECTION  XV. 
The  Commoner  Surgical  Diseases. 


CHAPTER  XLI. 

The  Commoner  Surgical  Diseases. 

Anesthesia;  Hernia;  Circumcision;  Appendicitis;  Intussusception  (Including 
Intestinal  Obstruction);  Peritonitis,  Acute,  Newly-born,  Early  Life, 
Pneumococcic;  Ascites;  Ischiorectal  Abscess;  Rectal  Polypus;  Fissure  of 
the  Anus;  Prolapse  of  the  Anus  and  Rectum;  Malignant  Tumors  in 
Childhood       549 


SECTION  XVL 
Diseases  of  the  Ear  and  Eye. 


CHAPTER  XLII. 

Diseases  of  the  Ear. 

General    Consideration;    Otoscopy;    Otitis;    Mastoiditis;    Infective    Cerebral 

Sinus  Thrombosis      565 


CONTENTS.  XV 

CHAPTER  XLIII. 

The  Commoner  Diseases  of  the  Eye. 

Page 
Foreign  Bodies;  Blepharitis;  Conjunctivitis,  Diphtheritic,  Chronic,  Granular; 
Chalazion;  Strabismus;  Keratitis;  The  Diagnostic  Significance  of  Ocular 
Affections;  Diagnostic  Hints       .    .  P/)/y^ 570 


fOffSffr 

SECTION  XVII.  ■    'Of^/l  ^ 


^  g< 


Diseases  of  the  Skin. 


%>?K 


CHAPTER  XLIV. 

Diseases  of  the  Skin. 

Ichthyosis;  Nevi;  Dermatitis  Exfoliativa  Neonatorum  (Ritter's  Disease); 
Pemphigus  Neonatorum;  Impetigo  Contagiosa;  Seborrhea  Capitis; 
Erythema  Multiforme;  Acute  Exfoliative  Dermatitis;  Eczema,  Acute, 
Subacute,  Chronic;  Psoriasis;  Miliaria;  Urticaria;  Furunculosis ;  Angio- 
neurotic Edema;  Herpes  Zoster 575 

CHAPTER  XLV. 

Parasitic  Skin  Diseases. 
Pediculosis;  Scabies;  Tinea  Tonsurans;  Tinea  Favosa;  Alopecia  Areata  .    .    .     588 
Index      593 


DISEASES  OF  CHILDREN. 


SECTION  I. 
THE  NEWLY-BORN. 


CHAPTER  I. 
THE  MANAGEMENT  AND  CARE  OF  PREMATURE  INFANTS. 

When  a  premature  infant  is  born  it  is  suddenly  deprived  of  a 
very  important  organ,  namely,  the  placenta,  which  has  a  selective 
action  for  the  developing  fetus.  Three  and  sometimes  four  factors 
mitigate  strongly  against  its  extrauterine  existence.  These  factors 
are  in  the  order  of  their  importance:  (1)  Undeveloped  heat  and 
respiratory  centers;  (2)  increased  susceptibility  to  infection;  (3) 
patent  umbilical  vessels  with  a  tendency  to  putrefaction;  and  (4) 
sometimes  possible  congenital  disease  from  its  progenitors. 

The  temperature  of  a  premature  babe  at  the  time  of  birth  varies 
from  98.6°  to  100°  F.  It  is  often  suddenly  introduced  into,  and 
examined  in  a  room  temperature  of  74°  F. ;  that  is,  with  a  variation  of 
24°  or  26°  F.  A  subnormal  temperature  undoubtedly  often  results, 
from  which  the  child's  undeveloped  heat  centers  fail  to  assist  it.  A 
lowered  temperature,  then,  is  the  first  evil  to  combat. 

Brothers  has  shown  that  more  than  one-half  of  all  deaths  under 
four  weeks  are  attributable  to  prematurity.  We  believe  that  many 
premature  infants  that  help  to  swell  the  mortality  statistics  may  be 
saved  by  timely  and  appropriate  directions  from  their  medical  attend- 
ants. More  viable  under-term  children  are  born  now  than  formerly, 
owing  to  better  methods  at  the  time  of  birth  and  to  such  surgical 
measures  as  Cesarean  section.  The  records  of  those  born  and  reared 
in  a  maternity  hospital  show  a  high  percentage  saved;  for  example: 
Maygrier,  at  the  Charit6  in  Paris,  has  saved  516  out  of  548  cases 
which  weighed  4i  to  5^  pounds  at  birth,  or  a  percentage  of  96.58 
per  cent.  Voorhees,  from  the  Sloane  Maternity,  has  an  average  of 
79.5  per  cent.,  but  these  cases  had  never  been  exposed  to  chilling 
and  transportation  and  had  the  advantage  of  woman's  milk  as  a 
pabulum.  It  must  be  remembered,  however,  that  our  maternity 
hospitals  have  no  facilities  for  caring  for  outside  cases,  and  these  are 
sent  after  a  variable  time  to  an  institution  which  has  an  incubator. 

1 


I  DISEASES  OF  CHILDREN. 

The  natural  solution  seems  to  be  incubator  life,  and  this  apparatus 
will  maintain  the  body  heat,  if  properly  managed  at  90°  F.,  but  it 
will  also  necessitate  that  the  babe  respire  this  superheated  air,  often 
vitiated  and  liable  to  germ  contamination.  Constant  and  eternal 
vigilance  is  required  to  keep  the  apparatus — even  the  best  obtainable 
— in  proper  working  order.  If  the  temperature  rises  suddenly,  a 
heat  stroke  results,  and  if  the  gas  pressure  falls  or  the  wind  changes. 


Fig.   1. — Incubator  with  outside  ventilation  and 
automatic  regulation  of  temperature. 


a  subnormal  temperature  may  follow.  The  premature  infant  de- 
livered at  home  should  therefore  be  placed  in  a  padded  basket 
or  crib,  (see  Fig.  2)  and  surrounded  with  hot-water  bottles  or  kept 
warm  with  an  electric  heater.  The  room  must  be  quiet  and  a 
sunny  one;  it  should  be  kept  at  78°  to  80°  F.,  preferably  heated  and 
ventilated  by  an  open  fireplace.  The  supply  of  fresh  air  should  be 
constant.  If  unavoidably  the  infant's  temperature  has  fallen  to 
subnormal,  a  warm  bath  and  gentle  friction  are  indicated  before 
supplying  the  swaddling  blankets  made  of  cotton  which  are  to  serve 
as   clothes.     The  importance  of  conserving  this  body  heat  may  be 


THE  MANAGEMENT  AND  CARE  OF  PREMATURE  INFANTS.       3 

emphasized  by  the  statistics  of  Budin  in  France.  Ninety  per  cent,  of 
the  premature  infants  died  who  had  a  temperature  between  90°  and 
92°  F. 

It  is  a  significant  fact  that  the  great  majority  of  cases  brought 
to  us  at  the  hospital  had  a  subnormal  temperature. 

The  weight  and  length  must  next  be  considered  in  its  relation 
to  viability  and  to  feeding.  If  the  weight  is  below  2i  pounds,  the 
premature  are  rarely  saved,  while  those  with  birth  weights  between 
2^  and  5  pounds  are  to  be  regarded  as  congenitally  feeble.     The 


Fig.  2. — Padded  basket-crib  suitable  for  premature  infants. 


length  of  time  in  utero  is,  however,  of  greater  importance  than  the 
birth  weight  in  establishing  the  prognosis.  Moore  saved  a  premature 
infant  born  at  the  sixth  month  of  gestation  which  was  nine  inches 
long  and  weighed  one  and  one-half  pounds  (this  babe  weighed  19 
pounds  at  the  end  of  fifteen  months).  Therefore,  if  the  child  is  born 
alive,  it  should  be  given  every  chance  to  live.  The  obstetrician  should 
immediately  place  the  babe  in  a  warmed  blanket  or  in  warm  cotton 
wool  and  have  hot  bottles  close  to  its  body  and  beneath  it.  Swad- 
dling clothes  are  later  used. 

The  next  problem  will  be  that  of  nutrition.  An  undeveloped 
digestive  tract  with  a  minimum  amount  of  secretions  and  an  over- 
active liver  will  demand  careful  consideration.  The  breast  milk  of  a 
woman  whose  child  is  about  ten  days  old  is  the  ideal  food;  this  should 
be  diluted  with  water  three  times  in  the  beginning,  and  later  twice, 
and  finally  undiluted  breast  milk  is  allowed,  especially  if  the  infant 
is  strong  enough  to  suck.     The  quantity  given  should  approximate 


DISEASES  OF  CHILDREN. 


1 


c 


one-fifth  of  the  baby's  weight,  if  it  is  above  four  and  a  half  pounds; 
but  very  small  amounts,  one  dram  every  hour,  should  be  ordered  for 
the  first  few  days,  and  very  gradually  increased. 

The  mother's  own  milk  should  be  pumped,  mas- 
saged, or  nursed  out  by  another  stronger  child,  but 
should  not  be  used  for  a  week  or  ten  days,  as  the 
colostrum  at  this  period  of  gesta- 
tion, as  shown  by  Adriance,  is  too 
rich  in  proteids.  A  wet  nurse  for 
a  short  period  or  a  small  amount 
of  breast  milk  (often  one  ounce  will 
suffice  for  twenty-four  hours) 
should  be  otherwise  obtained.  If 
this  is  impossible,  a  4  per  cent, 
lactose  solution  is  fed  for  a  few 
days,  followed  by  plain  whey,  and 
then  dram-feedings  of  modified 
milk,  beginning  with  0.5  per  cent, 
fat,  0.25  per  cent,  proteids,  and  4 
per  cent,  sugar  are  given,  gradually 
increasing  the  proteids  to  0.4  per 
cent,  and  later  to  0.8  per  cent. 
Sodium  citrate,  one  grain  to  the 
ounce,  will  assist  in  modifying  the 
curds. 

These  small  percentages  are 
best  obtained  from  the  laboratories, 
or  with  the  Deming  percentage 
modifier.  Peptonization  is  indi- 
cated if  the  stools  show  feeble  di- 
gestion. The  weaker  infants  are 
fed  with  a  dropper,  while  those 
capable  of  making  sucking  efforts 
are  fed  with  a  modified  Breck 
feeder.  This  can  be  made  from  a 
piece  of  glass  tubing  with  dropper 
nipples  applied,  the  one  being  perforated  by  three  small  holes 
(see  Figs.  3  and  4).  Gavage  is  dangerous.  We  have  found  milk 
in  the  trachea  and  bronchi  of  premature  infants  at  autopsy 
which  reached  there  via  the  tube.  The  medical  attendant  must  not 
be  discouraged  to  note  a  falling  off  in  weight  for  some  time.  It  is 
often  three  to  four  weeks  before  the  birth  weight  is  regained.     The 


Fig.  3.— Breck 
feeder  for  prema- 
ture infants. 


Fig.  4. — Home- 
made feeder. 


THE  MANAGEMENT  AND  CARE  OF  PREMATURE  INFANTS.       5 

nurse  must  be  ever  watchful  for  attacks  of  cyanosis,  which  must 
be  combated  with  two-  to  five-drop  doses  of  diluted  brandy,  or  cam- 
phor, gr.  ^,  in  sterile  olive  oil  hypodermatically.  The  icterus  which 
is  not  uncommon  and  which  is  usually  associated  with  constipation, 
often  produces  fatal  results.  It  is  best  treated  with  one-  or  two- 
twentieths  of  calomel. 

Daily  inunctions  of  liquid  petrolatum  (albolin)  are  given  in  lieu 
of  baths  for  cleanliness  after  the  usual  diapering.  After  the  first 
3'ear  these  premature  infants  are  not  necessarily  weak  and  puny,  but 
on  the  contrary  are  often  indistinguishable  from  the  full-term  infant. 
The  prognosis,  however,  should  always  be  considered  as  unfavorable, 
as  the  undeveloped  digestive  tract,  the  possibility  of  sepsis,  and  the 
defects  in  the  heart  all  mitigate  against  its  existence.  The  importance, 
however,  of  obtaining  breast  milk  cannot  be  overestimated,  for  it  is 
almost  impossible  to  raise  them  without  its  help.  In  our  experience, 
which  includes  over  one  hundred  premature  cases,  we  prefer  the  open 
method  of  treating  premature  infants  to  the  use  of  the  incubator,  and 
all  kinds  have  been  tried.  If  an  incubator  is  used,  only  the  kind 
having  connection  with  the  outside  air  should  be  employed,  as  these 
infants  are  exceedingly  susceptible  to  a  lack  of  fresh  air. 


CHAPTER  II. 
INJURIES  DURING  BIRTH. 

Deformity  of  Head. 

A  certain  pointing  toward  the  occiput  and  elongation  of  the  head 
are  noted  in  most  labors.  This  may  be  extreme  in  cases  where  a  long 
or  difficult  labor  has  resulted  in  excessive  molding  of  the  presenting 
part.  Fortunately,  little  damage  is  done  by  this  distortion  and  the 
head  usually  takes  on  its  natural  shape  in  a  few  days. 

Caput  Succedaneum. 

The  swelling  on  the  presenting  part  of  the  head  resulting  from 
pressure  is  known  as  caput  succedaneum.  It  consists  of  trans- 
uded serum  and  extravasated  blood  located  between  the  scalp  and 
pericranium  in  the  loose  connective  tissue  of  this  part.  It  has  a 
soft,  boggy  feeling.  Prolonged  or  difficult  labors  produce  this  effu- 
sion from  pressure  on  the  portion  of  the  head  that  presents.  No 
special  treatment  is  required,  as  the  absorbents  of  the  connective  tissue 
will  cause  its  disappearance  within  a  day  or  so. 

Cephalhematoma. 

Cephalhematoma  is  an  effusion  of  blood  between  the  bone  and 
the  periosteum  covering  it.  It  usually  appears  within  one  to  three 
days  after  birth.  Its  seat  may  be  any  portion  of  the  cranial  vault. 
Most  commonly  it  occurs  in  the  parietal  region,  sometimes  over  the 
temporal  or  occipital  bones.  The  overlying  integument  presents  no 
discoloration.  A  bony  ring  is  soon  developed  around  the  base 
from  the  secretion  of  the  periosteum.  The  effusion  is,  in  most  cases, 
limited  by  a  suture.  The  effused  blood,  as  a  rule,  undergoes  absorp- 
tion within  the  first  three  months  of  life.  In  rare  cases  suppuration 
ensues,  and  even  caries  of  the  subjacent  bone  may  occur.  The  fact 
that  the  tumor  does  not  communicate  with  the  brain  cavity,  which 
fact  can  usually  be  readily  made  out  by  palpation,  serves  to  distinguish 
this  affection  from  encephalocele.  To  differentiate  caput  succeda- 
neum and  cephalhematoma  it  ma}'  be  borne  in  mind  that  while  the 
former  is  nonfluctuating  and  disappears  in  a  few  days,  the  latter  is 

6 


INJURIES  DURING   BIRTH,  7 

soft  and  fluctuating,  presenting  a   marginal  ridge,  in  the  center  of 
which  the  skull  is  felt,  and  disappears  in  a  few  months. 

Treatment. — In  most  cases  no  treatment  is  called  for.  Should 
the  tumor  grow  it  may  be  strapped  with  adhesive  plaster,  the  head 
first  being  shaved.  Incision,  while  generally  condemned,  has  been 
practised  with  success.  It  offers  the  advantage  of  immediate  relief 
and  leaves  no  permanent  deformity.  The  effused  blood  can  usually 
be  removed  through  a  small  opening.  A  firm  compress  is  worn  for 
several  days  to  prevent  refilling.  It  is  needless  to  say  that  the  strictest 
asepsis  must  be  observed.  If  suppuration  occurs  the  usual  surgical 
treatment  of  abscess  must  be  carried  out. 

Injuries  to  Bone  and  Muscle. 

(a)  Bone. — The  soft  and  partially  developed  condition  of  in- 
fantile bone  renders  it  liable  to  injury  if  subjected  to  much  mechan- 
ical violence  during  delivery.  The  cranial  bones  are  especially 
liable  to  indentation  and  fracture  when  the  forceps  is  employed,  yet 
such  accidents  may  occur  in  spontaneous  labor.  Fracture  of  the  cra- 
nial bones  is  most  frequent  in  the  parietals.  When  the  brain  is  not 
injured  the  fracture  is  not  apt  to  result  seriously.  Rupture  of  intra- 
cranial blood-vessels  may  lead  to  fatal  hemorrhage.  Simple  inden- 
tations apparently  cause  little  if  any  damage  to  the  brain  structures. 
Gentle  efforts  at  reduction  may  be  attempted,  and  thus  the  normal 
shape  be  restored.  Fracture  of  the  inferior  maxillary  bone  may 
result  from  traction  with  the  fingers  in  unskillful  delivery  of  the  after- 
coming  head  in  breech  presentations.  Injuries  may  be  inflicted 
upon  the  vertebrae  or  the  spinal  cord,  with  resulting  paraplegia,  and 
they  are  almost  invariably  fatal.  Fractui*e  of  the  humerus  not  uncom- 
monly occurs  in  forcible  delivery  of  the  arm  in  breech  births,  or  sepa- 
ration of  the  epiphysis  from  the  shaft  of  the  bone  may  take  place. 
Fracture  of  the  clavicle  usually  results  from  violent  use  of  the  fingers 
in  extracting  the  after-coming  head.  The  femur  may  be  fractured 
from  misdirected  traction  with  fingers  or  fillet  in  breech  delivery. 

(6)  Muscle. — Hematoma  of  the  sternocleidomastoid  muscle  may 
result  from  artificial  interference  in  breech  extractions.  A  hard 
tumor  about  the  size  of  a  pigeon's  egg  may  be  seen  developing  in  this 
muscle,  usually  on  its  anterior  border.  It  is  noticed  between  the  ages 
of  one  and  six  weeks,  and  usually  disappears  by  absorption  in  a 
month  or  so.  The  muscle  fibers  are  sometimes  torn.  Hematoma 
of  the  sternocleidomastoid  may  lead  to  contracture  of  the  injured 
muscle  and  torticollis.  As  a  rule,  the  blood  is  spontaneously  ab- 
sorbed in  a  few  weeks. 


DISEASES  OF  CHILDREN. 


Birth  Palsies. 


Injuries  to  the  nerves  during  birth  may  be  central  or  peripheral. 
The  latter  are  fortunately  the  most  common  and  the  usual  types  are 
the  facial  and  upper-arm  paralysis. 

(a)  Facial  Paralysis. — Pressure  upon  the  seventh  or  facial 
nerve  at  the  stylomastoid  foramen  by  the  blades  of  the  forceps  is 
usually  responsible  for  facial  paralysis.  The  affection  is,  in  most 
cases,  unilateral,  and  will  not  be  noticed  when  the  infant  is  at  rest. 
When  nursing  or  crying,  the  palsy  of  the  affected  side  is  apparent. 
Recovery  usually  takes  place  spontaneously  in  a  few  weeks.  If  the 
paralysis  does  not  disappear  promptly,  faradism  may  be  employed. 
In  rare  cases  the  palsy  is  permanent. 


Fig.  5. — Erb's  paralysis. 


(6)  Upper-arm  Paralysis  (Erb's  or  Duchenne's  Paralysis. — 
The  next  most  frequent  peripheral  palsy  is  seen  in  the  arm.  Various 
conditions  during  birth  may  produce  compression  and  injury  of  the 
nerves  about  the  shoulder,  such  as  severe  pressure  of  the  obstetrician's 
finger  or  the  blunt  hook  in  the  axilla,  hematoma  of  the  sternocleido- 
mastoid, or  fracture  of  the  humerus  with  displacement  of  the  frag- 
ments. The  greatest  number  of  upper-arm  paralyses,  generally 
known  as  Erb's  or  Duchenne's  paralysis,  occur  after  breech  deliveries. 
The  injury  usually  results  from  traction  made  upon  the  shoulder  in 
the  delivery  of  the  head,  or  in  bringing  down  the  arm  when  it  is 
found  above  the  head  or  upon  the  head  in  vertex  deliveries,  and  is 
due,  as  a  rule,  to  stretching  of  the  fifth,  sixth,  and  seventh  cervical 
nerves.     Dragging  the  head  or  the  trunk  strongly  to  one  side  is 


INJURIES  DURING  BIRTH.  9 

usually  responsible  for  the  excessive  traction  upon  the  nerve  trunks 
of  the  injured  side.  The  deltoid,  biceps,  brachialis  anticus,  and  supi- 
nator longus  are  the  muscles  oftenest  affected.  In  mild  cases  the 
paralysis  may  not  be  noticed  for  some  weeks,  while  in  severe  ones  it 
will  usually  be  apparent  at  once. 

Diagnosis. — The  position  of  the  arm  is  characteristic.  It  hangs 
helpless  at  the  side  and  is  rotated  inward.  As  the  triceps  is  not  af- 
fected, the  child  can  extend  the  forearm,  but  cannot  flex  it.  After  a 
few  weeks  the  affected  muscles  show  more  or  less  atrophy,  but  the 
child  will  generally  begin  to  use  the  forearm.  The  diagnosis  of  Erb's 
paralysis  is  not,  as  a  rule,  difficult  when  seen  during  the  first  year. 
The  jDeculiar  position  of  the  arm  and  the  group  of  muscles  involved  are 
rarely  met  with  in  any  other  affection  at  this  early  age. 

Prognosis. — The  prognosis  will  depend  upon  the  severity  of  the 
symptoms  and  the  time  when  the  treatment  is  begun.  Spontaneous 
recovery  takes  place  in  some  cases  within  two  or  three  months.  If 
there  is  but  little  improvement  after  this  length  of  time,  spontaneous 
recovery  is  not  to  be  expected,  and  the  case  demands  active  treat- 
ment. In  some  cases  partial  paralysis  may  remain  for  several  years 
or  be  permanent. 

Treatment  should  be  begun  as  early  as  the  third  month,  and 
should  consist  in  frictions  or  massage  and  the  persistent  use  of  elec- 
tricity. If  the  muscles  react  to  the  faradic  current,  it  may  be  used; 
but  if  not,  the  galvanic  current  must  be  employed.  The  treatment 
must  be  continued  for  several  months,  or  until  recovery  is  nearly 
complete.     The  foregoing  treatment  applies  also  in  facial  paralysis. 

(c)  Central  Paralysis. — Meningeal  apoplexy,  followed  by  various 
paralyses,  is  one  of  the  untoward  results  of  prolonged  and  difficult 
labor.  This  is  more  apt  to  occur  with  the  first-born  child  owing  to 
the  unyielding  character  of  the  maternal  parts.  While  hemiplegia 
is  the  rule,  from  the  distribution  of  the  hemorrhage  over  the  surface 
of  one  side  of  the  brain,  there  may  be  less  diffused  local  hemorrhages 
resulting  in  paralysis  of  the  face  or  of  one  arm  or  leg.  In  eleven 
autopsies  following  this  injury,  as  reported  by  Dr.  McNutt,  the  hemor- 
rhage was  principally  at  the  base  of  the  brain  in  the  vertex  presen- 
tation, whereas  it  was  largely  on  the  convexity  in  the  breech  pres- 
entations. It  has  been  supposed  that  the  use  of  forceps  is  largely 
responsible  for  this  accident,  and  the  rough  and  careless  use  of  instru- 
ments is  doubtless  a  competent  cause.  The  writer  believes,  however, 
that  too  long  delay  in  the  application  of  the  forceps  when  the  head  is 
being  subjected  to  prolonged  pressure  is  oftener  responsible  for  this 
unfortunate  accident.     The  careless  use  of  ergot  before  delivery,  by 


10  DISEASES  OF  CHILDREN. 

inducing  a  tetanic  contraction  of  the  uterus,  also  favors  congestion 
of  the  fetal  brain. 

Symptoms  and  Prognosis. — The  symptoms  induced  by  men- 
ingeal extravasation  depend,  of  course,  upon  the  seat  and  extent  of 
the  effusion.  The  extravasation  is  frequently  located  over  the  motor 
convolutions,  and  if  not  extensive  the  hemiplegia  may  disappear  with 
the  absorption  of  the  blood.  If  more  extensive,  however,  the  infant 
may  be  stillborn  or,  if  living,  it  may  soon  die  from  asphyxia  or  in  a 
comatose  condition.  The  voluntary  muscles  in  such  cases  may  be  in  a 
spastic  condition  or,  more  rarely,  in  a  state  of  complete  relaxation. 
The  respiration  is  more  apt  to  be  depressed  and  irregular  than  the 
pulse.  Convulsions  may  occur  shortly  after  birth,  followed  by  coma. 
If  death  does  not  ensue  the  prognosis  for  the  extremities  affected  is 
good,  as  the  paralysis  gradually  improves,  often  undergoing  complete 
recovery.  The  brain,  however,  may  be  irreparably  injured,  as  shown 
by  subsequent  epilepsy  or  even  by  various  degrees  of  idiocy. 

Treatment. — The  treatment  must  be  preventive.  This  consists 
in  avoiding  as  much  as  possible  prolonged  pressure  upon  the  fetal 
head,  in  a  careful  use  of  the  forceps,  and  in  seeing  that  the  infant 
cries  immediately  after  birth,  thus  being  assured  that  the  lungs  are 
inflating.  It  is  of  great  importance  that  the  transition  from  the 
fetal  to  the  post-natal  circulation  should  at  once  take  place  at  birth, 
as  otherwise  great  damage  may  be  done,  particularly  to  the  brain; 
the  vessels  here  are  fragile  and  easily  ruptured.  If  the  infant  cries 
the  expanding  lungs  draw  off  the  excess  of  blood  that  may  do  damage 
elsewhere.  The  physician  should  give  his  first  attention  to  the  infant 
until  this  happens,  as  a  short  period  of  asphyxia  may  do  incalculable 
harm.  If  the  lungs  do  not  act,  it  is  well  to  let  the  cord  bleed  to  the 
extent  of  a  few  drams  to  prevent  severe  congestion  of  other  vital 
organs. 

Asphyxia. 

The  accidents  during  labor  that  induce  asphyxia  are:  sudden 
death  of  the  mother,  constant  pressure  upon  the  umbilical  cord,  severe 
compression  of  any  part  of  the  fetal  body,  especially  the  head,  as 
noted  above,  and  more  or  less  complete  detachment  of  the  placenta. 
In  consequence  of  the  air-hunger  induced  by  these  conditions,  a 
vigorous  infant  may  by  inspiratory  suction  take  in  secretions  of  the 
birth-canal,  which  may  cause  suffocation  after  birth  or  induce  pneu- 
monia later.  Very  feeble  infants  may  fail  to  establish  respiratory 
movements  after  birth,  owing  to  weak  or  defective  muscles  and  nerves. 
In  partial  asphyxia  there  is  congestion  and  suffusion  of  the  skin,  with 


INJURIES  DURING  BIRTH.  1], 

blueness  of  the  mucous  membranes,  full  pulse,  and  moderate  action 
of  the  reflexes.  As  the  symptoms  of  carbon-dioxid  poisoning  become 
more  marked,  the  pulse  grows  feebler,  the  skin  paler,  and  the  mucous 
membranes  assume  a  grayish-blue  color.  The  reflexes  are  likewise 
lost.  The  prognosis  in  the  latter  condition  is  exceedingly  bad.  In 
the  milder  degrees  of  birth-asphyxia  recovery  usually  ensues. 

The  Preventive  Treatment  consists  in  measures  addressed  to  the 
acceleration  of  tedious  labors  and  the  prevention  of  prolonged  pressure 
upon  the  fetal  parts,  especially  the  head.  During  descent  of  the  head 
malpositions  of  the  cord,  especially  prolapse,  or  winding  tightly 
around  the  neck,  must  be  looked  for  and,  if  possible,  corrected.  One 
of  the  possible  causes  of  asphyxia  will  be  removed  if  as  soon  as  the 
head  is  born  it  is  so  turned  that  the  face  shall  not  lie  in  a  pool  of  blood 
and  liquor  amnii.  At  the  same  time  the  mouth  and  fauces  can  hastily 
be  cleaned  of  mucus  with  a  moist  rag  drawn  over  the  finger  or  by 
means  of  a  soft  rubber  tube  with  a  rubber  bulb  attached.  In  moderate 
degrees  of  asphyxia  the  stimulus  of  the  cool  external  air  and  allowing 
a  dram  or  two  of  blood  to  escape  by  the  cord  will  be  sufficient. 
Should  this  not  suffice  the  chest  may  be  sprinkled  with  cold  water  to 
stimulate  the  reflexes,  while  the  infant  is  held  suspended  by  the  feet 
for  the  purpose  of  allowing  mucus  to  gravitate  from  the  air-passages. 
The  child  may  be  plunged  alternately  into  hot  and  cold  water.  The 
hot  water  should  have  a  temperature  not  exceeding  105°  F.  When 
these  external  stimuli  fail  to  excite  respiratory  movements,  resort 
must  be  had  to  artificial  respiration. 

The  child's  pharynx  should  first  be  cleared  of  mucus  and  other 
liquid  material  that  may  have  been  drawn  into  it  by  premature 
efforts  at  respiration.  The  simplest  and  most  effectual  method 
of  inflating  the  lungs  is  by  direct  insufflation — the  mouth-to-mouth 
method. 

Direct  Insuflaation. — The  child  is  placed  upon  its  back  with 
the  head  extended  by  means  of  a  small  pillow  or  roll  of  clothing 
placed  under  its  neck;  the  mouth  is  well  cleansed  and  a  towel  or  hand- 
kerchief is  spread  over  the  face.  With  one  hand  closing  the  nose, 
and  with  the  other  making  pressure  upon  the  epigastrium,  to  prevent 
the  inflation  of  the  stomach,  the  physician  forces  air  from  his  own 
gently  into  the  child's  mouth  and  inflates  the  lungs.  The  air  is 
expelled  by  gentle  pressure  upon  its  chest,  and  the  process  then' 
repeated.  When  properly  performed,  this  method  is  safer  than  passing 
a  catheter  or  other  instrument  into  the  trachea,  as  is  sometimes, 
practised.  Care  should  be  taken  lest  injury  be  done  to  the  aif-cells 
by  too  forcible  expansion. 


12  DISEASES  OF  CHILDREN. 

Various  methods  of  artificial  respiration  may  be  employed. 
Schultze's  method  is  most  commonly  employed.  The  operator  holds 
the  infant  suspended,  face  to  the  front,  his  index-fingers  being  hooked 
in  the  axillae,  the  thumbs  resting  on  the  front  of  the  chest  and  the 
fingers  upon  the  infant's  back.  The  lower  portion  of  the  child's  body 
is  now  swung  outward,  upward,  and  finally  toward  the  operator's  face, 
inverting  the  position.  Care  should  be  taken  that  the  trunk  is  most 
strongly  flexed  in  the  lumbar  region.  In  this  position  the  thorax 
is  compressed — expiration.  The  child's  lower  extremities  are  now 
swung  outward  away  from  the  operator's  body  and  downward  till 
the  child  hangs  suspended  by  its  axillae  in  the  position  first  described. 
In  this  position  of  the  child,  hanging  by  its  upper  extremities,  the 
abdominal  contents  fall  and  the  diaphragm  sinks — inspiration. 
To  assist  the  respiratory  movements  the  pressure  of  the  operator's 
thumb  is  relaxed  during  inspiration  and  increased  during  expiration. 
This  method  is  not  to  be  recommended  in  feeble  children. 

Laborde's  method  is  easy  to  apply  in  the  case  of  very  feeble 
infants.  It  consists  in  making  rhythmical  traction  upon  the  tongue, 
eight  to  ten  times  to  the  minute. 

After  the  respirations  have  been  started,  the  infant  must  be 
watched  to  see  that  they  continue.  It  may  be  advisable  in  some 
cases  to  administer  hypodermatically  ten  to  twenty  drops  of  whisky 
combined  with  1  minim  of  the  tincture  of  belladonna  or  ^iiy  grain  of 
strychnin.  In  most  cases  it  will  be  necessary  after  resuscitation  to 
apply  dry  heat  by  a  hot-water  bag  or  other  means.  In  asphyxia 
pallida  a  rectal  injection  of  water  at  a  temperature  of  110°  F.  is  of 
marked  service. 

Congenital  Atelectasis. 

Closely  allied  to  asphyxia,  and  often  associated  with  it,  is  a  per- 
sistence of  the  fetal  condition  of  the  lungs,  either  of  one  or  both  in 
whole  or  in  part.  It  is  due  to  failure  of  the  infant  to  completely 
inflate  the  lungs,  and  may  persist  for  a  considerable  time.  Sometimes 
it  results  in  death,  even  after  respiration  has  apparently  been  fully 
established. 

This  is  more  apt  to  involve  the  lower  lobes  than  the  upper  ones. 
It  is  frequently  seen  in  premature  infants  with  feeble  respiration. 
The  cause  may  also  be  injury  to  the  l)rain  from  pressure.  The  symp- 
toms are  those  of  deficient  respiratory  action,  such  as  pallor,  feeble 
cry,  and  poor  circulation,  with  very  little  expansion  of  the  chest- 
walls  over  the  affected  area.  Deep  inspiration  may  be  encouraged 
by  artificial  respiration,  and  the  vitality  conserved  by  the  external 


INJURIES  DURING  BIRTH.  13 

application  of  heat  and  the  judicious  administration  of  nourishment 
and  stimulants. 

Fetal  Death. 

Death  may  take  place  at  or  before  birth,  which  must  sometimes 
be  differentiated  from  asphyxia.  In  the  former  the  heart  pulsations 
cannot  be  felt  and  respirations  and  reflexes  are  absent.  In  the  latter 
the  heart  is  pulsating,  reflexes  are  present,  and  there  may  be  feeble 
attempts  at  respiration.  We  should  not  refrain  from  efforts  at 
resuscitation  because  the  heart-sounds  are  absent  or  no  pulsations 
can  be  felt  in  the  precordial  region.  The  distinction  between  a  dead- 
born  and  a  still-born  infant  can  usually  be  made  by  the  rapid  fall  of 
rectal  temperature  in  the  former  to  ten  or  fifteen  degrees  below  nor- 
mal and  by  the  widely  dilated  condition  of  the  pupils  in  the  dead-born. 
In  the  still-born,  artificial  respiration  may  be  employed,  and  the  hypo- 
dermatic injection  of  a  few  drops  of  whisky  and  gr.  ^^^  of  sulphate 
of  strychnin  may  be  given. 


CHAPTER  III. 
DISEASES  OF  THE  NEWLY-BORN. 

Acute  Infectious  Disease. 

While  the  newly-born  infant  seems  to  bear  a  sort  of  natural 
immunity  to  the  common  infectious  diseases  of  childhood,  it  is  pos- 
sible for  an  infant  to  be  infected  through  the  placenta  before  birth  or 
by  the  usual  methods  soon  after  birth.  While  the  symptoms  of  mea- 
sles, pertussis,  pneumonia,  scarlatina,  or  influenza  are  largely  the  same 
as  when  seen  later  on,  the  prognosis  in  the  newly-born  is  bad. 

Sepsis  of  the  Newly -born. 

An  infection  induced  by  pus-forming  organisms  such  as  the 
streptococcus  pyogenes  and  the  staphylococcus  pyogenes  aureus 
and  albus  may  be  seen  in  the  newly-born.  The  umbilicus  is  the 
most  vulnerable  spot  for  the  entrance  of  septic  poisons  during  or 
shortl}'  after  birth.  Upon  ligation  of  the  cord  the  blood  that  remains 
in  the  umbilical  veins  forms  small  thrombi  that  should  gradually 
harden  and  in  time  become  calcified,  forming  a  fibrous  cord  in  the 
same  manner  as  in  the  ductus  arteriosus  and  ductus  venosus.  In 
these  latter  structures  the  formation  of  thrombi  is  never  accompanied 
with  grave  consequences,  since  their  internal  situation  prevents  the 
access  of  infectious  agents.  Pyogenic  organisms,  however,  can 
readily  gain  access  to  the  umbilical  vein  and  give  rise  to  umbilical 
phlebitis  and  septicemia. 

There  is  a  constant  alteration  after  birth  in  the  blood-pressure  in 
the  umbilical  vein,  due  to  the  action  of  the  heart  and  lungs,  by  which 
a  sort  of  flux  and  reflux  is  produced.  This  favors  infection  of  the 
system  when  the  contents  of  this  vein  become  septic. 

This  grave  accident  is  liable  to  occur  when  the  mother  is  in  a 
septic  condition.  The  poison  may  be  produced  by  the  same  agents 
that  have  caused  the  puerperal  fever.  In  these  cases  of  sepsis  there  is 
a  puriform  or  yellow  softening  of  the  thrombi  that  fill  the  umbilical 
vein.  The  softened  matter  consists  of  pus-corpuscles  and  finely 
granular  matter  containing  micrococci.  This  sets  up  an  inflammation 
not  only  in  the  vessel  itself,  but  also  in  the  surrounding  tissues.     In- 

14 


DISEASES  OF  THE  NEWLY-BORN.  15 

fective  emboli  may  be  carried  to  various  parts  of  the  body.  As  the 
micrococci  enter  the  umbilical  vein  from  the  umbilical  fossa,  owing 
to  the  perviousness  of  this  vessel,  the  structures  near  at  hand,  espe- 
cially the  liver,  bear  the  first  brunt  of  the  septic  inflammation.  The 
latter  organ  is  usually  found  much  diseased  or  degenerated.  There 
is  jaundice,  with  constant  elevation  of  temperature  and  other  symp- 
toms of  general  septic  infection.  If  the  infant  lives  long  enough 
peritonitis  will  probably  develop,  and  sometimes  empyema,  pleuro- 
pneumonia or  even  meningitis.  In  all  cases  evidence  of  severe  illness 
and  prostration  are  present.  Cutaneous,  mucous,  or  visceral  hemor- 
rhages may  supervene  at  any  time.  The  abdomen  is  generally  swollen 
and  tender,  and  dirty-looking  pus  may  be  seen  oozing  from  the  navel; 
slight  pressure  about  the  umbilicus  will  often  cause  pus  to  exude  if  it 
is  not  otherwise  apparent.  The  fecal  discharges  may  be  of  natural 
appearance,  but  the  urine  is  usually  highly  colored.  The  infant  refuses 
nourishment,  and  there  may  be  vomiting  of  greenish  matter.  Severe 
nervous  symptoms,  such  as  convulsions  or  coma,  supervene  before 
death.  While  the  umbilicus  is  the  most  common  seat  of  septic  infec- 
tion, any  sore  or  abrasion  elsewhere  may  afford  entrance  to  germs. 
Erysipelatous  eruptions  on  the  abdomen,  chest,  or  other  parts,  are 
the  most  frequent  manifestations  of  such  infection. 

Multiple  joint  inflammation  and  suppuration  may  appear  as  evi- 
dences of  a  general  pyemia,  and  a  few  cases  of  osteomyelitis  have  been 
reported. 

Treatment. — The  prophylactic  treatment  of  sepsis  consists  in 
the  careful  antiseptic  management  of  labor  and  proper  attention  and 
cleanliness  in  i-eference  to  the  navel.  Localized  sepsis  may  be  com- 
bated by  the  topical  use  of  peroxid  of  hydrogen,  bichlorid  of  mercury 
solution,  or  other  strong  antiseptic  agents. 

The  remedial  treatment  of  systematic  infection  consists  in  full 
stimulation  and  general  support  and  the  judicious  use  of  external  re- 
frigerant measures.  In  the  latter  condition,  however,  treatment  is 
generally  futile.  Empyema,  pleuropneumonia,  erysipelas  and  any 
other  local  effect  of  infection  must  be  treated  symptomatically. 

Umbilical  Hemorrhage. 

Hemorrhage  may  take  place  from  the  stump  of  the  cord  shortly 
after  birth  from  insecure  ligation,  from  shrinkage  of  the  funis,  or  from 
slipping  of  the  ligature.  Laceration  of  the  cord  between  the  abdomen 
and  the  ligature  may  also  be  responsible  for  hemorrhage.  Secondary 
hemorrhage,  usually  between  the  fifth  and  fifteenth  days,  may  occur, 


16 


DISEASES  OF  CHILDREN. 


even  though  the  cord  has  been  securely  ligated  and  properly  watched. 
The  trouble  may  be  due  to  changes  in  the  walls  of  the  minute  blood- 
vessels, allowing  transudation,  or  to  imperfect  coagulability  of  the 
blood.     In  the  latter  case  the  hypogastric  artery  and  the  umbilical 

artery  and  vein  have  not 
been  tightly  occluded  by 
the  usual  fibrinous  plug. 
The  hemorrhage  is  ac- 
counted for  by  syphilis, 
jaundice,  hemophilia,  or  by 
depraved  health  on  the 
part  of  the  parents. 

Treatment. — The  great 
majority  of  cases  are  fatal 
from  the  impossibility  of 
controlling  the  hemorrhage. 
In  the  milder  ones  a  com- 
press of  gauze  tightly  ap- 
plied with  adhesive  strips 
may  be  sufficient. 

Adrenalin  (xthtt)  i^s-Y 
also  be  used  to  moisten  the 
compress.  In  the  most 
obstinate  cases  it  may  be 
necessary  to  transfix  the 
umbilicus  by  two  needles 
placed  at  right  angles  with 
a  figure-of-eight  ligature 
placed  tightly  around  them. 

Umbilical  Vegetations. 

Fungous  granulations 
at  times  appear,  arising 
from  the  floor  of  the  um- 
bilical fossa,  shortly  after 
the  falling  of  the  cord. 
They  may  attain  the  size 
of  a  pea,  and  they  usually 
exude  a  bloody  serum,  which  may  induce  excoriations  in  the  sur- 
rounding skin.  The  granulations  may  gradually  atrophy  after  weeks 
or  months  of  sluggish  existence.  The  constant  moisture  and  dis- 
charge is,  however,  a  source  of  irritation,  and  it  is  best  to  destroy  the 


Fig.  6. — Adhesive  plaster  dressing  for  umbil- 
ical hernia,  made  with  two  pieces  overlapping. 

{Pisek's  method.) 


DISEASES  OF  THE  NEWLY-BORN.  17 

growths.  This  can  be  accomplished  by  repeated  cauterization  with 
the  solid  stick  of  nitrate  of  silver  or,  better  still,  by  passing  a  ligature 
around  the  base  of  the  mass  and  amputating  the  exuberant  granula- 
tions with  scissors.  A  dry  dressing  of  boric  acid  or  subnitrate  of 
bismuth  may  then  be  applied. 


Umbilical  Hernia. 

There  is  a  tendency,  especially  on  the  part  of  badly-nourished  in- 
fants, for  the  gut  to  protrude  a  little  at  the  umbilicus.  It  is  hence 
desirable  to  keep  a  firm  abdominal  binder  in  place  for  the  first  two 
or  three  months.  After  this  time  if  a  protrusion  persists,  the  hernia 
may  be  retained  by  long  strips  of  adhesive  plaster.  It  may  be  necessary 
to  keep  up  this  support  for  several  months.  The  dressing  may  be 
examined  and  changed  every  few  days  to  be  sure  the  pressure  stays 
in  the  right  place.  If  the  skin  is  irritable  from  frequent  pulling  off  of 
the  strips  of  plaster,  part  of  the  plaster  may  only  be  removed  and  the 
new  plaster  applied  over  the  ends  of  the  old  strips  and  thus  tightened 
over  the  hernia.  The  skin  must  be  kept  scrupulously  clean  and  fre- 
quently dusted  with  powder.  In  older  infants,  an  abdominal  truss 
may  occasionally  do  good  service.  It  is  rare  for  this  form  of  umbilical 
hernia  to  last  through  childhood.  In  exceptional  cases  when  the  rup- 
ture increases  rapidly  in  size  operative  interference  may  be  considered. 


Epidemic  Hemoglobinuria. 

(Winckel's  Disease.) 

This  form  of  hemoglobinuria  is  very  rarely  seen  in  the  newly-born 
and  then  usually  in  institutions.  It  begins  a  few  days  after  birth  in 
healthy  infants  with  constitutional  symptoms  of  depression  shown 
by  a  weak  rapid  pulse  and  general  asthenia.  An  icterus  soon  develops 
that  becomes  very  marked  and  is  noted  over  the  whole  body.  The 
urine  is  soon  lessened  in  amount,  contains  traces  of  albumin  and 
hemoglobin  in  large  amounts.  Casts  are  occasionally  also  found. 
The  color  of  the  urine  may  be  dark  or  smoky.  The  disease  pro- 
gresses rapidly,often  terminating  in  one  or  two  days.  There  may  be 
marked  cyanosis  with  convulsions  or  coma  before  the  close  of  life. 
The  disease  is  evidently  an  outcome  of  some  sort  of  infection,  but 
the  microbe  has  not  yet  been  isolated.  Treatment  does  not  seem 
to  be  of  much  avail. 
2 


18  DISEASES  OF  CHILDREN. 

Fatty  Degeneration  of  the  Newly -born. 

(Buhl's  Disease.) 

This  is  a  very  rare  disease  that  acts  like  some  form  of  pyogenic 
infection.  It  is  characterized  by  fatty  degeneration  of  the  heart,  liver, 
and  kidneys  with  hemorrhages  from  any  of  the  mucous  membranes 
or  into  the  various  serous  cavities  or  viscera.  T?he  spleen  and  liver 
are  both  usually  enlarged.  The  disease  is  accompanied  by  great 
prostration  and  may  last  one  or  two  weeks.  Icterus  may  be  present. 
The  treatment  is  supporting  and  symptomatic,  but  not  able  to  save 
life. 

Icterus  Neonatorum. 

This  is  a  common  affection  of  the  newly-born.  Two  distinct 
varieties  are  recognized,  differing  widely  in  cause  and  prognosis  and 
known  as  the  mild  and  grave  forms. 

(a)  Mild  Form, — Two  divergent  theories  have  been  advanced 
to  account  for  this  form.  The  first  considers  the  jaundice  to  be  purely 
hematic;  the  second  theory  regards  it  as  hepatic  in  origin.  Bile  is 
first  formed  in  the  liver  and  then  carried  into  the  circulation,  the  resorp- 
.  tion  being  due  either  to  congestion  or  to  edema  of  the  hepatic  tissue. 
It  seems  highly  probable  that  both  these  theories  may  apply  in 
different  instances,  and  doubtless  many  cases  of  icterus  neonatorum 
are  to  be  satisfactorily  explained  only  by  taking  into  consideration  a 
morbid  condition  of  both  the  blood  and  the  liver,  thus  combining  the 
hematic  and  hepatic  theories. 

The  intense  congestion  of  the  skin  observed  during  the  first  few 
hours  of  life  often  produces  a  yellowish  coloration  that  cannot  be  con- 
sidered jaundice.  It  is  of  the  same  nature  as  the  discoloration  of  the 
skin  following  an  ordinary  cutaneous  bruise.  The  yellow  tint  is  at 
first  seen  only  on  deep  pressure,  but  as  the  erythema  fades  the  yellow- 
ness increases.  The  conjunctivae  are  not  colored,  and  the  urine  appears 
normal.  This  yellowness  is  usually  first  noticed  on  the  second  day, 
and  may  continue  a  few  days  or  a  week. 

The  term  "true  icterus"  can  be  applied  only  to  those  cases  in 
which  the  yellow  discoloration  of  the  skin  is  caused  by  a  staining  by  the 
bile  pigments.  This  more  often  occurs  in  cases  of  prolonged  or  difficult 
labor,  in  children  born  asphyxiated  or  before  term,  and  in  generally 
feeble  infants.  It  is  very  frequently  seen  in  foundling  asylums.  It 
may  appear  as  early  as  a  few  hours  after  birth,  but  usually  is  not  marked 
until  the  second  or  third  day.  In  very  mild  cases  the  yellow  color 
may  appear  only  on  the  face,  chest,  and  back,  the  conjunctivae  being 


DISEASES  OF  THE  NEWLY-BORN.  19 

but  faintly  tinted  and  the  urine  and  feces  normal  in  appearance.  In 
severer  forms  the  urine  may  be  high  colored  enough  to  stain  the 
linen,  and  the  jaundiced  hue  may  extend  to  the  arms  and  abdomen. 
Some  infants  present  a  yellowish  discoloration  of  the  whole  body,  with 
typical  clay-colored  stools.  In  most  cases  the  jaundice  has  disap- 
peared by  the  eighth  or  tenth  day.  It  may  persist  for  several  weeks. 
In  rare  cases,  after  having  much  diminished,  it  reappears  with  renewed 
intensity.  No  matter  how  extensive  this  form  of  jaundice  may  be, 
it  causes  very  little  constitutional  disturbance.  The  liver  may  be 
slightly  enlarged,  and  occasionally  there  are  symptoms  of  intestinal 
indigestion.  A  few  small  doses  of  calomel  or  mercury  with  chalk  will 
be  all  the  medication  required. 

(6)  Grave  Form. — This  form  is,  fortunately,  rare,  and  may  be 
produced  by  several  different  conditions.  Defects  in  the  bile-ducts 
will  first  be  mentioned  as  among  the  commonest  causes.  In  some 
cases  all  the  large  bile-ducts  have  been  absent;  in  others  the  ductus 
communis  choledochus  has  been  narrowed,  obliterated,  or  entirely 
absent.  Sometimes  a  fibrous  cord  has  been  found  in  place  of  the 
gall-duct.  The  cystic  duct  has  been  absent  and  the  gall-bladder 
in  a  rudimentary  condition.  Accompanying  an  obliteration  of  the 
gall-ducts  cirrhosis  is  usually  found  in  the  liver,  which  will  be  more 
or  less  marked,  according  to  the  length  of  time  the  infant  survives. 
The  liver  is  generally  enlarged.  Jaundice  that  is  due  to  obstruction 
or  obliteration  of  the  biliary  passages  may  appear  a  few  hours  after 
birth  and  soon  acquire  a  marked  intensity.  It  often,  however,  does 
not  appear  for  one  or  two  weeks  after  birth.  The  yellowish  discolor- 
ation of  the  skin  may  vary  from  day  to  day,  at  times  being  much 
more  intense  than  others.  The  conjunctivae  are  yellow.  The  fecal 
discharges  lose  color  and  have  an  offensive  odor,  while  the  urine  stains 
the  napkin  a  yellow  or  greenish-brown.  The  spleen,  as  well  as  the 
liver,  is  usually  enlarged,  which  partially  accounts  for  the  increase 
in  size  of  the  abdomen.  Umbilical  hemorrhage  is  a  grave  and  not 
infrequent  symptom  in  this  form  of  jaundice.  The  bleeding  is  not 
sudden  and  profuse,  but  begins  as  an  oozing  shortly  after  the  separa- 
tion of  the  navel  string.  It  is  apt  to  commence  at  night.  Death  is 
always  hastened  by  this  accident,  and  exhaustion  from  loss  of  blood 
is  added  to  that  induced  by  indigestion  and  malassimilation.  There 
may  also  be  a  species  of  general  purpura,  bleeding  taking  place  from 
the  nose,  mouth,  or  stomach.  Infants  may  live  for  several  months 
with  impervious  or  defective  bile-ducts,  though  death  usually  takes 
place  earlier  from  failure  of  nutrition. 

Another  form  of  grave  icterus  neonatorum  is  observed  in  connec- 


20  .         DISEASES  OF  CHILDREN. 

tion  with  certain  inflammatory  changes  in  the  liver,  usually  taking 
the  form  of  an  interstitial  hepatitis,  with  which  may  be  conjoined  in- 
flammation of  the  biliary  canals.  This  lesion  is  apt  to  be  one  of  the 
results  of  congenital  syphilis,  as  is  likewise  perihepatitis,  which  may 
cause  a  complete  obliteration  of  the  biliary  passages.  The  latter  form 
of  inflammation  often  involves  the  connective  tissue  surrounding  the 
common  duct,  the  portal  vein,  and  the  hepatic  artery  on  the  under 
surface  of  the  liver.  These  cases,  however,  may  not  always  be  of 
syphilitic  origin.  Perhaps  the  commonest  manifestation  of  the  grave 
form  of  icterus  in  the  newly-born  is  seen  in  connection  with  septic 
poisoning  that  is  generally  accompanied  with  phlebitis.  This  has 
been  noted  under  the  head  of  sepsis.  Later  researches  seem  to  prove 
that  the  bile  itself  may  carry  the  infective  agent. 

Tetanus  Neonatorum. 

Although  this  disease  is  distributed  through  a  wide  geographical 
area,  it  is  most  apt  to  be  found  in  filthy  surroundings.  Something 
beside  filth,  however,  is  necessary;  there  must  be  a  specific  cause.  This 
consists  in  the  tetanus  bacillus,  sometimes  called  Nicolaier's  bacillus 
which  produces  tetanotoxin,  a  most  virulent  poison.  It  may  exist 
in  straw  or  dust  from  hay,  which  explains  the  fact  that  horses  are 
subject  to  tetanus  and  that  traumatic  tetanus  is  often  seen  among 
laborers  who  are  employed  about  farms  and  stables. 

The  disease  usually  begins  during  the  first  ten  days  of  life,  and 
the  onset  is  apt  to  be  preceded  by  great  fretfulness.  Disinclination 
to  nurse  is  soon  followed  by  rigidity  of  the  voluntary  muscles,  usually 
starting  in  the  masseters.  The  rigidity  increases,  reaching  its  maxi- 
mum in  from  twelve  to  twenty-four  hours.  The  head  is  thrown  back, 
and  there  is  a  general  flexion  of  the  extremities.  One  peculiarity  of 
the  disease  is  that  while  the  toes  are  flexed  the  great  toes  are  adducted. 
There  may  be  some  relaxation  at  times,  especially  during  sleep,  but 
there  are  constant  exacerbations,  provoked  by  any  peripheral  irrita- 
tion. Respiration  and  circulation  may  be  extremely  embarrassed, 
and  opisthotonus  may  be  present  during  these  exacerbations. 

The  temperature  is  irregular,  but  usually  high.  Toward  the 
end  the  pulse  becomes  rapid  and  feeble  and  death  takes  place  from 
exhaustion. 

Treatment. — While  the  specific  cause  of  the  disease  may  gain 
entrance  at  any  point  of  the  body  when  the  necessary  lesion  exists, 
the  umbilical  wound  is  undoubtedly  the  seat  of  infection  in  the  great 
majority  of  cases  of  tetanus  neonatorum;  hence  the  utmost  cleanliness 


DISEASES  OF  THE  NEWLY-BORN.  "21 

must  be  observed  in  cutting  the  cord  and  in  dressing  it.  The  scissors, 
the  ligature,  and  the  entire  management  of  the  navel,  cord,  stump, 
and  the  umbilical  wound  must  be  rigidly  aseptic.  The  excess  of  the 
gelatinous  matter  should  be  stripped  from  the  cord,  and  a  dry,  anti- 
septic dressing  applied.  Speedy  mummification  of  the  stump  is  the 
best  safeguard  against  infection.  Special  care  must  be  exercised  in 
the  umbilical  dressings  where  the  dwelling  is  easy  of  access  to  stable- 
yards  containing  horse-manure  or  loose  earth. 

When  the  disease  is  once  established  it  is  almost  invariably  fatal. 
In  cases  of  suppuration  at  the  umbilicus,  frequent  cleansing  with  a 
solution  of  mercuric  bichlorid  of  suitable  strength  should  be  employed. 
With  reference  to  drugs,  the  two  most  valuable  are  potassium  bromid, 
gr.  iv  every  two  to  four  hours,  and  chloral  hydrate,  gr.  j  every  hour. 
The  extract  of  calabar  bean  from  y^  to  y^  grain  may  be  given  hy- 
podermatically.  While  these  are  administered  the  infant  must  be 
given  nourishment  frequently,  and  stimulants  should  be  freely  em- 
ployed. The  difficulty  of  swallowing,  however,  is  a  source  of  embar- 
rassment in  satisfactorily  carrying  out  these  measures.  Nourishment 
may  be  given  by  the  rectum  or  by  a  nasal  tube,  A  tetanus  antitoxin 
is  now  produced  by  several  manufacturing  chemists,  but  so  far  the 
experience  reported  in  the  serum  treatment  of  tetanus  neonatorum 
has  been  rather  negative. 

Conjunctivitis. 

The  conjunctival  membrane  in  the  newly-born  is  very  sensitive, 
and  frequently  the  seat  of  inflammation.  A  mild  inflammation  is 
often  seen,  unattended  by  swelling  of  the  lids,  the  inner  surface  being 
reddened  and  covered  with  a  slight  viscous  secretion.  The  eyes  must 
be  kept  cleansed  by  frequent  bathing  or  irrigation  wdth  a  saturated 
solution  of  boric  acid.  A  little  vaselin  may  be  applied  to  the  lids  to 
prevent  retention  of  the  secretion  by  adhesion  of  their  edges. 

Ophthalmia  Neonatorum. 

This  form  of  purulent  conjunctivitis  may  be  due  to  infection  by 
the  gonococcus  in  the  severer  cases  or  by  various  pyogenic  cocci  in 
the  milder  ones  (Koch- Weeks  bacillus).  If  the  disease  manifests 
itself  by  the  second  or  third  day,  the  infection  probably  took  place 
during  birth.  When  there  is  a  delay  of  a  week  or  more,  however,  the 
virus  has  probably  been  conveyed  by  careless  attendants,  by  soiled 
fingers  or  other  infected  objects.     The  inflammation  is  of  an  intensely 


22  DISEASES  OF  CHILDREN. 

virulent  type,  involving  both  the  ocular  and  palpebral  conjunctivae. 
The  sac  is  filled  with  a  grayish  mucopurulent  secretion,  and  there  is 
intense  chemosis.  The  subconjunctival  connective  tissue  and  skin  are 
much  swollen,  so  that  the  eye  can  only  with  difficulty  be  opened. 
There  are  photophobia,  pain  in  the  eye,  and  rise  of  temperature. 
Unless  the  symptoms  quickly  subside,  the  eye  is  irreparably  damaged 
by  ulceration  and  partial  destruction  of  the  cornea.  The  inflam- 
mation begins  in  one  eye,  but  soon  attacks  the  other  unless  it  is 
effectively  protected. 

The  Prophylactic  Treatment  consists  in  employing  antiseptic 
vaginal  douches  in  the  parturient  woman  when  there  is  any  muco- 
purulent discharge,  and  dropping  two  or  three  drops  of  a  2  per  cent, 
solution  of  silver  nitrate  into  each  eye  immediately  after  birth,  after 
the  method  proposed  by  Crede. 

Curative  Treatment. — When  the  inflammation  has  actually  begun 
the  eye  must  be  kept  as  free  of  pus  as  possible  by  constant  wash- 
ings with  a  saturated  solution  of  boric  acid.  The  swelled  and  puffy 
lids  should  have  applied  to  them  every  few  minutes  gauze  com- 
presses that  have  been  kept  upon  a  cake  of  ice,  and  the  pus  must  be 
removed  every  hour  or  two.  Constant  cleansing  and  cooling  of  the 
surface  will  require  the  services  of  a  careful  nurse  night  and  day.  A 
2  per  cent,  solution  of  nitrate  of  silver  or  of  bichlorid  of  mercury, 
one  or  two  grains  to  the  pint,  may  be  instilled  between  the  lids  every 
two  or  three  hours,  according  to  the  severity  of  the  case.  As  this 
affection  so  frequently  results  in  blindness,  it  is  well,  if  possible,  to 
have  the  advice  of  an  oculist.  Protargol  in  5  per  cent,  or  argyrol 
10  per  cent,  solution  can  be  recommended  as  a  substitute  for  nitrate 
of  silver.  It  has  the  advantage  of  being  less  painful,  and  is  equally 
efficient. 

If  the  disease  is  limited  to  one  side  an  effort  should  be  made  to 
protect  the  sound  eye  from  infection  by  applying  a  compress  moistened 
with  an  antiseptic.  The  pupil  must  be  dilated  with  sulphate  of 
atropin  if  the  cornea  is  attacked. 

Mastitis. 

The  mammary  glands  of  the  new-born  infant  often  secrete  a 
milk-like  substance,  which  appears  between  the  fourth  and  tenth  days 
after  birth.  During  this  time  there  may  be  swelling  of  the  glands, 
which  gradually  abates  with  the  subsidence  of  the  secretion  until, 
usually  by  the  twentieth  day  at  the  latest,  both  secretion  and  swelling 
have  disappeared.     In  some  cases,  however,  the  glands  may  remain 


DISEASES  OF  THE  NEWLY-BORN.  23 

engorged  and  tender,  and  suppuration  ensue.  This  implies  infection, 
and  is  exceedingly  rare  when  proper  antiseptic  precautions  have  been 
observed  during  and  after  labor. 

Treatment. — When  there  is  simple  swelling  the  parts  may  be 
cleansed  with  soap  and  water  and  bathed  with  a  weak  antiseptic 
solution,  either  of  carbolic  acid  or  bichlorid  of  mercury.  Gentle 
support  with  absorbent  cotton  and  a  bandage  will  also  be  indicated. 
If,  in  spite  of  this,  suppuration  occurs,  there  will  be  rise  of  temperature 
and  the  local  signs  of  abscess.  Then  early  incision,  under  proper 
antiseptic  precautions,  constitutes  the  treatment. 

Spontaneous  Hemorrhages  in  the  Newly-born. 

In  addition  to  the  accidental  hemorrhages  during  the  process  of 
delivery  caused  by  pressure  effects,  we  may  occasionally  have  spon- 
taneous hemorrhages  during  the  first  week  of  life  that  are  independent 
of  birth.  These  hemorrhages  may  occur  in  connection  with  various 
forms  of  sepsis,  with  congenital  syphilis  or  from  unknown  causes. 
A  general  predisposing  cause  doubtless  exists  in  the  great  alteration 
in  the  circulation  induced  by  the  transition  from  fetal  to  extrauterine 
life,  from  the  rapid  changes  taking  place  in  the  blood  at  this  time,  and 
the  fragile  state  of  the  walls  of  the  blood-vessels.  The  blood  may 
ooze  from  the  mucous  membrane  of  the  nose,  mouth,  gastrointestinal 
tract,  umbilicus,  or  vagina.  The  skin  may  also  be  affected,  especially 
at  the  occiput,  along  the  back  and  wherever  pressure  is  apt  to  be 
exerted.  There  may  likewise  be  small  extravasations  in  the  various 
viscera,  but  these  are  not  usually  recognized  during  life.  The  hemor- 
rhage takes  the  form  of  slow,  continuous  oozing  and  is  not  apt  to  last 
more  than  one  or  two  days.  While  the  actual  loss  of  blood  may  not 
be  great,  a  large  number  of  the  cases  die  from  exhaustion,  as  losses  of 
blood  are  not  well  tolerated  at  this  time.  The  bleeding  is  apt  to 
start  from  the  intestinal  tract,  called  melena  neonatorum,  when  the 
infant  may  be  restless  or  somnolent,  with  bloody  stools,  and  occasion- 
ally vomit  hemorrhagic  masses.  The  umbilicus  may  begin  to  show 
oozing  a  few  days  later  and  hematuria  is  sometimes  noted.  Where  the 
hemorrhage  is  limited  to  the  nose,  congenital  syphilis  is  probably 
the  cause.  While  the  etiology  of  some  of  these  cases  is  obscure,  the 
condition  is  different  from  hemophilia,  and  the  hemorrhages  usually 
stop  spontaneously  in  a  few  days. 

The  prognosis  is  bad,  the  infants  succumbing  to  exhaustion. 
Among  709  cases  collected  by  Townsend  79  per  cent.  died.  The 
treatment  consists  in  trying  to  keep  up  the  strength  by  careful  feeding 


24  DISEASES  OF  CHILDREN. 

and  stimulation  and  by  employing  adrenalin  in  connection  with  the 
bleeding  surfaces  when  they  can  be  reached. 


Various  diseases  and  affections  that  are  often  seen  in  the  newly- 
born,  but  not  confined  to  this  period,  will  be  discussed  in  their  appro- 
priate sections.  Among  these  may  be  noted  tuberculous  infection, 
congenital  syphilis,  thrush  or  sprue,  colic  and  indigestion,  edema,  and 
pemphigus. 


.59: 


SECTION  II. 
HYGIENE  OF  INFANCY. 


CHAPTER  IV. 
HYGIENE  OF  INFANCY. 

After  birth  a  careful  inspection  of  the  infant  should  be  made  to 
discover  any  defects  that  may  be  present.  The  body  should  then  be 
thoroughly  oiled,  and,  if  the  infant  is  cold  or  gives  evidence  of  poor 
vitality,  it  may  be  wrapped  in  cotton  batting  and  put  in  a  warm  place 
for  rest.  Vigorous  children  may  be  bathed  in  water  at  100°  F.  shortly 
after  the  oiling  and  then  dressed.  The  first  bath  must  always  be  given 
expeditiously  in  a  warm  room.  A  dry  dressing  is  best  for  the  cord, 
which,  after  a  thorough  powdering,  may  be  wrapped  in  sterile  gauze. 
A  daily  sponging  of  the  body  with  castile  soap  and  warm  water  will  take 
the  place  of  the  bath  until  after  the  cord  separates,  A  pad  of  sterile 
gauze  may  be  applied  over  the  umbilicus  for  several  weeks  and  kept  in 
position  by  the  abdominal  binder. 

The  eyes  can  be  cleansed  with  a  saturated  solution  of  boric  acid 
or  a  2  per  cent,  solution  of  nitrate  of  silver  where  a  purulent  vaginal 
discharge  has  existed  in  the  mother.  The  mouth  may  be  gently  wiped 
Out  with  boiled  water  and  a  teaspoonful  of  tepid  water  given  to  swallow. 

Clothing. 

The  clothing  consists  of  an  abdominal  binder  of  flannel,  which, 
in  a  few  months  may  be  changed  in  vigorous  infants  to  a  knitted  band 
with  shoulder  straps.  The  binder  should  not  press  so  tightly  as  to  re- 
tard the  free  expansion  of  the  lungs  in  breathing.  Next  will  come  a 
shirt  with  a  little  extension  below  to  which  the  diaper  may  be  attached 
by  pinning  and  then  a  flannel  petticoat.  Finally  a  dress  of  some  light 
material  will  complete  the  raiment.  Care  must  be  taken  to  have  the 
clothing  neither  too  tight  nor  too  loose.  In  the  former  case,  the 
free  movements  of  the  chest,  abdomen  and  legs  are  interfered  with, 
while  in  the  latter  instance  the  clothing  creases  or  works  up  and  down 
in  a  manner  to  cause  much  discomfort.  Long,  warm  stockings,  with 
knitted  bootees  will  keep  the  lower  extremities  protected  in  cold 
w^eather,  and  in  the  warm  season,  short,  thin  socks  may  be  substituted. 
In  early  infancy  the  clothing  is  made  long  enough  to  well  cover  the 

25 


26  DISEASES  OF  CHILDREN. 

feet,  but  it  is  not  necessary  to  have  dresses  and  petticoats  unduly' 
long  so  as  to  drag  on  the  feet.  The  Gertrude  patterns  are  excellently 
adapted  to  the  dressing  of  infants  as  the  several  pieces  may  be  put  on 
at  one  time,  obviating  unnecessary  handling.  Diapers  may  be  made  of 
linen,  cotton,  stockinet,  or  canton  flannel,  according  to  the  season,  care 
being  taken  to  have  them  snugly  applied  and  warm.  Watchfulness  of 
the  nurse  is  required  to  have  them  quickly  changed  after  being  soiled. 

The  Nursery. 

This  should  be  a  large  well-ventilated  room  with  a  sunny  ex- 
posure. The  temperature  should  be  kept  constant — from  68°  to  70°  F. 
during  the  day  and  at  night  from  65°  to  55°  F.,  according  to  the  age  and 
vitality  of  the  infant.  An  intake  of  fresh  air  without  a  draft  may  be 
accomplished  by  fitting  a  board  under  the  lower  window  sash.  If 
possible  heat  the  room  with  an  open  fire  on  account  of  the  ventilation. 
When  furnace  heat  is  employed,  a  thorough  airing  twice  a  day  by 
widely  opened  windows  is  desirable. 

Bathing. 

After  the  cord  has  separated,  a  daily  bath  may  be  given.  For  the 
first  six  months  the  temperature  of  the  water  may  vary  from  98° 
to  100°  F. ;  from  six  to  twelve  months,  95°  to  98°  F.,  and  after  one 
year  it  may  be  as  low  as  90°  F.  A  good  grade  of  soap — French  or 
castile — may  be  used,  and  the  lather  removed  by  plunging  the  infant 
in  the  water.  The  skin  must  be  thoroughly  but  gently  dried  without 
undue  friction,  and  the  folds  of  the  skin  and  genitals  powdered.  The 
prepuce  is  to  be  retracted  to  prevent  the  collection  of  smegma.  Finally, 
the  eyes  and  mouth  may  be  cleansed  with  a  warm  solution  of  boric 
acid.  When  the  skin  is  thin  and  irritable,  or  the  seat  of  eczema,  bran 
baths  may  do  well.  In  severe  cases  of  eczema,  the  skin  may  be 
cleansed  by  rubbing  with  sweet  oil  or  vaselin. 

Exercise  and  Fresh  Air. 

When  awake,  the  infant  should  not  be  allowed  to  lie  continuously 
in  its  crib,  as  the  gentle  exercise  of  being  held  or  carried  about  is  bene- 
ficial. They  should  always  be  taken  up  for  feeding.  The  arms  and  legs 
must  not  be  so  constricted  by  the  clothing  as  to  prevent  easy  move- 
ments and,  when  undressed,  a  little  time  for  free  play  of  all  the  muscles 
is  beneficial.  In  warm  weather,  the  infant  can  be  taken  out  of  doors 
as  early  as  the  second  or  third  week,  in  spring  and  fall  at  from  four  to 
six  weeks,  but  if  born  in  winter,  unless  the  weather  is  mild,  it  may  be 
wiser  to  give  it  its  airings  in  the  house  until  spring.     In  cold  weather 


HYGIENE  OF  INFANCY.  27 

it  is  best  to  give  the  outing  between  10  a.  m.  and  3  p.  m.  when  the  sun 
is  out,  but  the  face  and  eyes  must  be  carefully  protected  from  the 
sun's  rays.  Never  expose  an  infant  to  wind.  When  the  temperature 
of  the  air  is  below  30°  F.  it  is  better  to  stay  at  home,  except  in  the 
case  of  very  strong  infants.  The  baby  can  sleep  out  of  doors,  but 
care  must  always  be  taken  to  see  that  it  is  sufficiently  warm  during 
the  winter  months.  In  very  cold  weather  or  when  there  is  melting 
snow,  the  infant  may  get  fresh  air  by  being  warmly  clothed,  put  in  a 
room  with  a  sunny  exposure  and  have  the  window  opened.  The  room 
must  then  be  otherwise  closed  to  prevent  a  draft.  It  is  possible  in 
this  way  to  avoid  the  dust  of  the  streets  in  windy  weather.  It  is  like- 
wise safer  to  take  the  fresh  air  in  this  manner  in  damp,  foggy  weather 
when  there  is  no  sun. 

General  Habits. 

It  is  well  to  start  early  in  training  the  infant  to  habits  of  regularity. 
Sleep  is  encouraged  by  putting  the  infant  in  its  crib  with  a  firm  mat- 
tress, but  with  the  head  low,  resting  on  a  folded  pad,  darkening  the 
room,  and  attending  to  proper  ventilation.  Rocking  as  a  preliminary 
or  accompaniment  of  sleep  is  undesirable.  If  feeding-time  comes  during 
sleep  the  infant  can  be  awakened  for  this  purpose,  as  he  will  usually 
sleep  again  after  nursing  or  learn  to  wake  at  the  proper  time.  The 
nurse  need  not  hasten  to  take  a  baby  up  the  moment  it  arouses  and 
cries,  as  it  will  frequently  go  to  sleep  again  after  a  few  moments  of  rest- 
lessness. During  wakeful  hours,  and  especially  late  in  the  day,  the 
infant  must  not  be  excited  by  too  much  playing  and  attention,  as  this 
induces  delayed  and  disturbed  sleep.  The  very  young  infant  should 
sleep  most  of  the  time,  from  eighteen  to  twenty-two  hours  daily  during 
the  first  months.  At  six  months  the  baby  usually  sleeps  two-thirds 
of  the  time,  and  at  one  year  over  half  the  time. 

Much  can  usually  be  accomplished  by  an  early  training  of  the 
bowels.  As  early  as  the  third  month  the  infant  can  be  placed  at  regular 
times  on  a  small  commode  for  this  purpose,  taking  care  to  support  the 
baby  in  the  proper  position.  At  a  year,  efforts  may  be  made  to  train 
the  bladder  by  encouraging  the  young  infant  to  indicate  his  desire 
for  urination.  After  many  trials  progress  will  be  made  in  this  direction. 

The  greatest  regularity  in  feeding  must  be  entailed  from  the  first, 
but  the  necessary  details  will  be  considered  in  the  chapter  on  feeding. 
Water  must  always  be  regularly  given,  even  the  newly-born  getting  a 
few  teaspoonfuls  daily. 

The  young  infant  must  always  be  kept  quiet,  as  the  rapidly  grow- 
ing nervous  system  suffers  from  romping  and  too  much  attention. 
This  must  especially  be  enforced  late  in  the  day. 


CHAPTER  V. 

WEIGHT  AND  DEVELOPMENT. 

It  is  important  to  have  a  record  of  the  birth  weight  in  every  case. 
The  male  infant  usually  weighs  a  little  more  than  the  female.  In  a 
series  of  200  cases  examined  by  the  writer  the  males  weighed  from  6 
to  8  pounds  and  the  females  from  5^  to  7  pounds.  As  many  of  these 
were  born  in  institutions  the  averages  of  light  weight  were  fairly  large. 
Seven  pounds  may  be  considered  a  good  average  birth  weight.  As  far 
as  initial  weight  may  be  considered  a  gauge  of  vitality,  6J  pounds  will 


Fig.  7. — Platform  scale  for  weighing  the  baby. 

show  a  good  vitality,  5h  pounds  a  rather  poor  vitality  and  from  4  to  5 
pounds  a  very  poor  vitality  at  the  start.  During  the  first  few  days 
there  is  generally  a  loss  of  from  four  to  six  ounces  after  which  there 
should  be  a  steady  gain.  It  must  be  remembered,  however,  that  babies 
are  apt  to  gain  irregularly  at  short  intervals.  One  day  the  infant  may 
show  a  gain  of  an  ounce  and  the  next  day  a  quarter  of  that  amount 
while  doing  perfectly  well.     Again,  the  weight  may  remain  stationary 

28 


WEIGHT  AND  DEVELOPMENT. 


29 


for  a  day  or  so,  and  then  jump  up  two  ounces  in  twenty-four  hours. 
According  to  Rotch,  there  should  be  an  average  daily  gain  from  birth 
to  five  months  of  20  to  30  gm.  (two-thirds  of  an  ounce  to  an  ounce), 
and  from  five  to  twelve  months  of  10  to  20  gm.  (one-third  to  two-thirds 
of  an  ounce).  This  would  mean  an  average  weekly  gain  during  the 
first  five  months  of  about  four  and  a  half  ounces  to  seven  ounces,  and 
from  five  to  twelve  months  of  from  about  two  and  a  half  to  four  and  a 
half  ounces. 

The  infant  should  double  its  birth  weight  at  five  or  six  months, 
and  treble  it  at  from  twelve  to  fifteen  months.  The  weighing  should 
be  done  by  the  same  person  either  on  grocer's  scales  or  those  specially 


Fig.  8. — Normal  infant.    Typical  attitude. 


constructed  for  infants.  Daily  weighings  are  deceptive  and  undesir- 
able. During  the  first  six  months,  once  a  week  is  sufficient,  and,  in 
the  second  six  months,  once  in  two  weeks  is  often  enough  in  cases  that 
are  doing  well.  Careful  records  should  be  kept,  and  charting  is  con- 
venient for  reference. 

The  length  of  the  new-born  baby  is  slightly  greater  in  the  male 
than  in  the  female.  In  the  series  already  noted  that  was  examined  by 
the  writer,  the  males  averaged  50  cm.  (19.6  inches)  and  the  females 
48.6  cm.  (19.1  inches).  In  private  practice,  with  healthy  parents, 
the  length  will  average  about  20  inches.  Growth  in  length  is  most 
rapid  during  the  first  month,  a  little  less  so  during  the  second,  the 
rapidity  decreasing  with  each  month.  The  following  figures  are 
taken  from  Rotch:  The  average  increase  for  the  first  month  is  about 
4.5  cm.  (If  inches);  for  the  second  month  about  3.0  cm.  (H  inches); 
for  the  third  to  the  fifteenth  month  about  1  to  1.5  cm.  (^  to  f  inch); 


30  DISEASES  OF  CHILDREN. 

for  the  first  year  about  20  cm.  (8  inches);  for  the  second  year  about 
9  cm.  (3^  inches);  for  the  third  year  about  7.4  cm,  (3  inches). 

Just  after  birth  the  trunk,  arms,  legs,  and  head  have  peculiar  con- 
formations. The  body  is  of  an  elliptical  shape,  with  the  widest  part 
at  about  the  center  over  the  liver,  in  the  region  of  the  lower  ribs.  The 
two  ends  of  the  ellipse,  represented  by  the  thorax  and  pelvis,  are  small 
and  not  well  developed.  The  arms  are  stronger  and  better  developed 
than  the  legs.  During  intrauterine  life  the  baby  is  placed  in  a  sort 
of  squatting  position  with  the  legs  drawn  up  and  curled  inward.  This 
explains  why  the  legs  of  the  young  infant  are  not  straight,  but  show  a 
decided  bowing  of  the  tibia  and  fibula.  The  soles  of  the  feet  also 
tend  to  point  inward.  The  head  is  larger  than  the  chest  at  this  time, 
with  a  very  short  neck,  and  the  baby  assumes  a  position  of  general 
flexion. 

While  infants  at  birth  may  vary  in  size,  each  individual  should 
develop  in  proper  proportion,  the  various  parts  of  the  body  bearing  a 
symmetrical  relationship  to  one  another.  The  circumference  of  the 
head  is  greater  than  the  circumference  of  the  chest  at  birth,  and  re- 
mains so  up  to  the  middle  of  the  first  year,  when  they  begin  to  approxi- 
mate in  size;  at  the  end  of  the  first  year  the  chest  expands  to  a  greater 
circumference  than  the  head.  If  later  than  this  time  the  circumfer- 
ence of  the  head  remains  greater  than  that  of  the  chest,  it  is  an  indica- 
tion of  rickets  or  hydrocephalus.  The  following  diagrams  done  in 
scale  from  200  measurements  will  show  to  the  eye  the  average  relation- 
ships found  at  various  ages. 

The  Head. — The  sutures  of  the  skull  should  be  ossified  by  the 
sixth  month;  the  posterior  fontanel  closes  at  the  end  of  the  second 
month  and  the  anterior  fontanel  from  the  sixteenth  to  the  eighteenth 
months.  Any  deformities  of  the  head  due  to  prolonged  pressure  in 
difficult  labors  are  usually  overcome  during  the  first  few  weeks.  After 
birth  and  with  increase  in  age,  there  is  noted  a  gradual  and  steady 
enlargement  of  the  great  circumference  of  the  skull,  and,  from  this, 
of  its  estimated  volume.  Although  no  intellectual  growth  can  be  said 
to  take  place  under  two  years,  there  should  be  an  active  evolution  of 
the  front  of  the  brain,  with  increase  of  the  perceptions.  The  first  rapid 
growth  of  the  brain  after  birth  is  more  in  bulk  than  in  the  size  and  com- 
plexity of  the  convolutions.  Hence  in  early  infancy  the  higher  centers 
have  but  a  slight  development  and  function.  With  proper  evolution, 
the  convolutions  grow  and  become  arranged  in  functional  groups, 
which  groups,  by  their  growth,  alter  and  modify  the  shape  of  the  in- 
fantile skull.  If  the  skull  is  small  or  improperly  shaped  in  any  part, 
the  brain  in  such  area  is  imperfectly  developing.     A  certain   amount 


WEIGHT  AND  DEVELOPMENT. 


31 


of  asymmetry  is,  however,  found  in  all  skulls  as  in  other  members 
of  the  body  and,  unless  very  marked,  has  no  great  significance. 

The  principle  of  biology  that  the  development  of  the  individual 
reproduces  on  a  small  scale  the  development  of  the  race,  is  well  shown 
in  the  infant's  brain.  The  higher  centers  and  the  association  fibers 
are  developed  late  in  the  child;  they  are  likewise  the  latest  acquirements 


LENGTH 


20.7 


LENGTH 


WEIGHT 
7  LBS.12  0Z. 


NEWBORN 


26.2 


LENGTH 


WEIGHT 
15.4  LBS. 


6  MOS. 


WEIGHT 
18  LBS.  9  OZ. 


Fig.  9a. 


12  MOS. 

-Diagrammatic  table  of  relative  measurements. 


of  the  race.     The  lower  and  more  fundamental  animal  traits  are  trans- 
mitted by  inheritance  in  greater  degree  than  the  higher  ones. 

The  skull  changes  considerably  in  its  proportions  during  the  first 
years  of  life,  and  then  more  slowly  up  to  the  end  of  the  seventh  year, 
when  it  has  very  nearly  attained  its  full  size.  At  birth,  the  circum- 
ference of  the  head  averages  from  thirteen  to  fourteen  inches,  at  the 
end  of  the  second  year  about  eighteen  inches,  at  the  seventh  year  about 
twenty  and  a  half  inches,  and  at  the  completion  of  growth  twenty- 
two  or  more  inches. 


32 


DISEASES  OF  CHILDREN. 


Just  after  birth  the  brain  and  nerve  centers  act  only  automatically, 
or  by  reflex  action.  Touch  and  taste  are  present  at  birth,  but  the 
baby  is  deaf  for  the  first  few  days  and  it  will  not  follow  an  object  with 
its  eyes  until  the  third  week.  The  eyes  should  never  be  exposed  to 
bright  lights.     By  the  third  month  the  baby  reaches  out  its  arms  for 


LENGTH 


29.8 


LENGTH 


WEIGHT 
22  LBS.  2  OZ. 


18  MOS. 


WEIGHT 
24  LBS. 


24  MOS. 

Fig.  9b. — Diagrammatic  table  of  relative  measurements. 

objects  and  may  recognize  individuals.  The  rudiments  of  memory  are 
now  developed,  and  by  the  fourth  or  fifth  month  a  few  people  may  be 
remembered  and  recognized.  It  is  not  until  the  third  year,  however, 
that  memory  develops  very  rapidly.  Efforts  at  speaking  usually 
begin  at  the  end  of  the  first  year  when  single  words  may  be  uttered, 
and  at  the  close  of  the  second  year  short  sentences  may  be  tried. 


WEIGHT  AND  DEVELOPMENT.  33 

The  Spine. — The  spinal  column  is  curved  but  very  flexible.  In 
early  infancy  the  so-called  normal  curves  are  not  developed  above  the 
sacrum,  but  there  is  one  long  curve  in  the  shape  of  a  convexity  above 
the  latter  bone.  With  the  strengthening  of  the  spinal  muscles,  and 
when  the  child  begins  to  stand  and  walk,  the  normal  cervical,  dorsal, 
and  lumbar  curves  begin  to  develop.  As  the  child  grows  older  the 
spine  becomes  less  flexible  and  more  rigid  with  increased  power  in  the 
spinal  muscles.  There  is,  however,  much  more  flexibility  all  through 
childhood  than  in  adult  life;  when  the  spine  loses  its  mobility,  and 
especially  when  it  is  stiff  or  painful  on  motion,  caries  may  be  suspected. 
At  birth  the  spinal  cord  extends  as  far  as  the  third  lumbar  verte- 
bra, while  in  the  adult  the  lowest  portion  of  the  cord  is  opposite  the 
second  lumbar  vertebra.  The  spinous  process  of  the  fourth  lum- 
bar vertebra  is  about  on  a  level  with  a  line  drawn  between  the  highest 
points  of  the  crests  of  the  ilia. 

Glands  and  Viscera. — The  lacrimal  glands  are  usually  not 
developed  sufficiently  to  shed  tears  for  three  or  four  months.  The  di- 
astase-forming organs — the  salivary  glands  and  pancreas — act  very 
feebly  during  the  first  two  or  three  months.  The  sebaceous  glands  are 
early  active,  as  seen  just  after  birth  in  the  vernix  caseosa  and  later  in 
dry  seborrhea. 

The  thymus  is  large  at  birth,  increasing  slightly  in  size  to  the  end 
of  the  second  3^ear  and  then  remaining  uniform  in  size  until  puberty, 
when  it  undergoes  atrophy. 

The  stomach  is  somewhat  like  a  vertical  sac  at  birth,  but  gradually 
develops  in  a  horizontal  direction;  the  intestines  are  relatively  long 
with  a  sigmoid  flexure  that  is  accentuated  and  with  sharper  curves 
than  in  older  subjects.  The  intestinal  muscles  are  weak,  which  ex- 
plains the  ease  with  which  the  bowel  becomes  distended  with  gas. 
The  appendix  is  very  long  and  narrow  in  lumen.  The  liver  is  large, 
reaching  a  little  below  the  free  margin  of  the  ribs. 

The  bladder  is  well  developed  and  usually  extends  up  into  the  ab- 
dominal cavity  on  account  of  the  smallness  of  the  pelvis.  In  female 
infants  the  bladder  may  be  mistaken  for  the  uterus  at  autopsy.  The 
testicles  should  be  located  in  the  scrotum  at  birth,  but  they  may  re- 
main undescended  in  the  abdomen  or  caught  in  the  inguinal  canal. 

The  Muscles. — In  the  musculature,  the  greatest  relative  strength 
is  shown  in  the  hands  and  arms  for  a  time  after  birth,  At  about  three 
months  the  muscles  of  the  neck  have  developed  sufficiently  to  allow 
the  infant  to  hold  up  its  head  in  an  uncertain  way.  At  the  seventh  or 
eighth  month  the  muscles  of  the  back  have  become  strengthened  so 
that  the  baby  can  sit  up,  and  shortly  after  this  it  may  be  allowed  to 
3 


34  DISEASES  OF  CHILDREN. 

creep.  Free  play  should  be  given  to  the  muscles  of  the  arms  and  legs 
from  the  first,  as  muscular  and  bony  development  are  thereby  encour- 
aged. The  bones  of  the  legs  thus  grow  and  straighten  out,  but  this 
will  be  checked  if  the  infant  is  made  to  sustain  the  weight  of  the  body 
too  soon.  The  average  baby  should  not  be  encouraged  to  stand  before 
the  twelfth  month.  Efforts  to  walk  may  be  started  from  then  on  to 
the  fifteenth  or  sixteenth  months.  When  walking  has  been  established, 
the  legs  should  be  straight. 

Dentition. — The  process  of  dentition  begins  early  in  intrauterine 
life,  and  the  cutting  of  the  temporary  or  milk-teeth  should  be  completed 
at  the  end  of  infancy.  At  birth,  although  nothing  but  smooth  gums 
are  to  be  seen,  the  alveolar  processes  enclose  the  twenty  temporary  teeth 
in  embryo.  When  beginning  to  come  through  the  gums,  they  usually 
appear  in  groups.  Even  in  healthy  infants  there  is  often  some  varia- 
tion in  the  order  and  time  of  the  eruption  of  these  first  teeth,  but  the 
earliest  to  be  cut  are  usually  one  or  both  of  the  middle  lower  incisors 
at  the  sixth  or  seventh  month.  The  rest  are  gradually  evolved, 
generally  in  the  following  order:  upper  central  incisors,  upper  lateral 
incisors,  lower  lateral  incisors,  four  anterior  molars,  four  canines,  and 
finally  the  four  posterior  molars.  The  following  table  may  serve 
as  a  general  guide : 

Middle  lower  incisors,  sixth  to  eighth  month. 

Upper  central  incisors,  eighth  to  twelfth  month. 

Upper  lateral  incisors,  tenth  to  twelfth  month. 

Lower  lateral  incisors,  twelfth  to  fifteenth  month. 

Four  anterior  molars,  fourteenth  to  sixteenth  month. 

Four  canines,  eighteenth  to  twentieth  month. 

Four  posterior  molars,  twentieth  to  thirtieth  month. 

As  in  other  functions  there  is  more  or  less  variation  within  the 
limits  of  health;  such  irregularity  as  the  lateral  incisors  being  cut  be- 
fore the  central  incisors  may  occasionally  be  seen.  In  rare  cases  in- 
fants are  born  with  teeth,  but  these  are  poorly  developed  and  lost 
early.  Certain  unusual  cases  of  rickets,  contrary  to  the  common  rule, 
may  show  very  early  dentition,  perhaps  beginning  as  early  as  the 
third  month,  but  such  teeth  are  poor. 

Delayed  Dentition. — Much  delay  in  teething  is  an  evidence  of 
faulty  nutrition  or  constitutional  disease,  principally  rickets.  If  an 
infant  has  cut  no  teeth  by  the  end  of  the  first  year  there  will  nearly 
always  be  marked  evidences  of  rickets  present.  The  latter  disease  is 
the  commonest  cause  of  delayed  dentition.  The  teeth  of  rickety  chil- 
dren are  often  poorly  developed  and  prone  to  decay,  even  the  second 
dentition  may  be  similarly  affected  by  this  disease.     Cretinism  is 


WEIGHT  AND  DEVELOPMENT.  35 

another  cause  of  very  slow  dentition.     In  general,  bottle-fed  babies 
are  slower  in  cutting  teeth  than  those  brought  up  on  the  breast. 

Disturbances  of  Dentition. — Many  bodily  disturbances  for- 
merly attributed  to  teething  are  now  known  to  have  other  causes  that 
have  been  revealed  by  more  accurate  diagnosis  and  pathology.  This 
is  a  period  of  rapid  growth  and  instability,  especially  of  the  digestive 
and  nervous  systems.  Many  troubles  at  this  time  are  due  more  to 
faulty  care  and  feeding  than  to  any  normal  physiological  activity  and 
growth.  Still  a  certain  number  of  infants  do  show  disturbances  at  this 
time  that  are  apparently  due  to  the  eruption  of  teeth,  as  careful  ex- 
amination fails  to  show  other  cause.  There  may  be  evidences  of  ner- 
vous discomfort  shown  by  constant  restlessness  and  fretfulness,  dis- 
inclination to  take  food,  and  various  grades  of  indigestion.  There  is 
drooling  with  swollen  gums,  and  the  infant  keeps  putting  its  hands  into 
its  mouth.  As  light,  irregular  temperature  may  also  develop  that  will 
be  aggravated  by  indigestion  if  food  is  forced  in  too  great  amount  or 
strength.  In  a  few  cases  the  infant  seems  much  sicker,  with  high 
fever  and  severe  nervous  symptoms,  such  as  semi-stupor  or  convulsions. 
Rickety  babies  are  prone  to  the  latter.  Most  cases,  however,  show  the 
disturbances  of  dentition  rather  by  an  aggravation  of  any  existing 
trouble  that  otherwise  might  hardly  be  noticeable. 

The  treatment  consists  in  careful  regulation  of  the  diet,  which 
will  usually  take  the  form  of  temporarily  weakening  the  food,  and  in 
giving  a  sedative,  such  as  sodium  bromide.  Incising  the  gums  is  not 
advised.  Any  diarrhea  at  this  time  must  receive  prompt  and  careful 
attention. 

Care  of  Temporary  Teeth. — The  teeth  must  be  cleansed  twice 
daily  by  gently  rubbing  up  and  down  with  a  very  soft,  wet  tooth-brush. 
The  health  and  preservation  of  the  temporary  teeth  are  necessary  to 
favor  a  good  set  of  permanent  teeth.  Any  pyogenic  germs  allow^ed  to 
lodge  in  the  roots  may  injure  the  permanent  teeth;  milk-teeth  must 
accordingly  be  filled  if  carious  and  preserved  as  long  as  possible.  They 
also  tend  to  preserve  the  alveolar  shape. 

Permanent  Teeth. — There  are  thirty-two  in  the  complete  set. 
The  first  molars  are  usually  the  earliest  teeth  to  appear  in  the  second 
dentition,  at  the  sixth  or  seventh  year.  Then  the  central  and  lateral 
incisors,  from  the  seventh  to  the  ninth  year;  the  bicuspids  from  the 
ninth  to  the  tenth  year;  the  canines  from  the  twqlfth  to  the  fourteenth 
year;  the  second  molars  from  the  twelfth  to  the  sixteenth  year;  and  the 
third  molars,  or  wisdom  teeth,  from  the  seventeenth  to  the  twenty-first 
year,  or  even  later. 

The  proper  development  of  the  permanent  teeth  may  be  interfered 


36  DISEASES  OF  CHILDREN. 

with  by  malnutrition  or  repeated  attacks  of  stomatitis  which  may  cause 
a  poor  formation  of  dentine  and  enamel.  The  ends  of  the  incisors  and 
molars  may  show  constrictions  and  erosions.  Carious  teeth  frequently 
cause  earache,  neuralgia,  adenitis  in  the  neck,  and  poor  nutrition  from 
chronic  indigestion  due  to  imperfect  mastication. 

Hutchinson's  Teeth. — Congenital  syphilis  will  sometimes  induce 
a  change  in  the  upper  central  incisors  of  the  permanent  teeth  only, 
known  by  the  name  of  their  discoverer.  They  are  small  and  peg- 
shaped,  with  scooped-out  grinding  edges,  usually  deflected  inward; 
occasionally  they  are  deflected  outward. 

Growth  during  Childhood. 

The  increase  in  weight  and  height  depends  upon  race  and  climate 
as  well  as  on  the  size  and  physique  of  the  parents.  It  is  thus  evident 
that  no  absolute  rules  can  be  given  for  comparison  that  will  apply  to 
all  children.  We  have  already  given  data  as  regards  infancy,  when 
growth  is  steady  and  rapid.  After  the  period  of  infancy,  growth  is  not 
relatively  so  rapid  and  takes  place  more  in  cycles.  It  depends  very 
largely  upon  good  heredity,  and  a  healthy  well-nourished  state  during 
the  first  years  of  life.  Biological  researches  have  shown  that  favorable 
embryonic  conditions  and  good  nutrition  during  the  earliest  years  have 
the  greatest  influence  in  determining  the  full  height  and  development 
of  the  individual.  If  a  child  is  fortunate  in  its  birth  and  well  nourished 
up  to  its  fifth  or  sixth  year,  there  will  probably  be  a  normal  growth 
thereafter,  as,  even  if  there  are  poor  conditions  later  on,  nature  will 
probably  be  able  to  compensate  for  them.  Each  individual  has  a 
certain  normal  size  to  attain  which  will  usually  be  reached  if  the  first 
years  have  been  favorable.  It  is  difficult  to  make  up,  however,  for 
early  unfavorable  conditions. 

The  two  principal  periods  of  acceleration  of  growth  occur  during 
the  second  dentition  and  at  the  period  of  adolescence.  This  roughly 
corresponds,  first,  with  the  period  from  six  to  nine  years  in  boys  and 
girls,  and  second,  from  eleven  to  thirteen  in  girls  and  from  fourteen 
to  sixteen  in  boys.  This  cycle  of  increase  in  height  should  precede 
and  be  shortly  followed  by  an  increase  in  weight.  There  also  tends  to 
be  some  variation  in  growth  at  different  seasons.  In  a  series  of  cases 
quoted  by  Tanner,  the  period  of  most  rapid  increase  in  height  among 
seventy  boys,  from  seven  to  fifteen  years  of  age,  was  found  to  be  from 
April  to  August,  and  the  least  from  August  to  December,  while  the 
greatest  increase  in  weight  occurred  from  August  to  December,  and 
the  least  from  April  to  August. 


WEIGHT  AND  DEVELOPMENT. 


37 


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38 


DISEASES  OF  CHILDREN. 


Whenever  there  is  a  rapid  increase  in  height,  the  child  is  apt  to  grow 
thin  and  anemic,  as  the  making  of  bone  particularly  uses  up  the 
red  blood-corpuscles.  The  children  then  become  nervous  and  irri- 
table, requiring  extra  care  at  home  and  school. 


IS^yrs. 


12>i  yrs. 


9'A  yrs. 


6^  yrs. 


43.9 
inches 


50.0 
iuclies 


45.2  lbs. 


55.4 
inches 


59.6  lbs. 


62.9 
inches 


76.9  lbs. 


107.4  lbs. 


Fig.  9c. — Diagrammatic  table  of  relative  measurements. 

In  order  to  present  a  guide  of  average  growth,  the  following  tables 
have  been  combined  and  compiled  from  the  studies  of  Boas  on  the 
rate  of  growth  in  height  and  of  Burke  on  the  weight  of  American 
children: 

Table  of  height  and  weight  of  American  boys. 


Years 

Average  height  (Boas) 

Average  weight  (Burke) 

6i 

43.9  inches 

45.2  pounds 

7i 

46 . 0  inches 

49.5  pounds 

8* 

48 . 8  inches 

54.5  pounds 

9i 

50.0  inches 

59.6  pounds 

12i 

55.4  inches 

76.9  pounds 

15i 

62.9  inches 

107.4  pounds 

m 

67.4  inches 

WEIGHT  AND  DEVELOPMENT.  39 

Table  of  height  and  weight  of  American  girls. 


i'ears 

Average  height  (Boas) 

Average  weight  (Burke) 

6i 

43.3  inches 

43.4  pounds 

7i 

45 . 7  inches 

47.7  pounds 

8J 

47 . 7  inches 

52.5  pounds 

n 

49 . 7  inches 

57.4  pounds 

m 

56 . 1  inches 

78.7  pounds 

15i 

61.6  inches 

106.7  pounds 

18* 

114.9  pounds 

Mental  and  Moral  Growth. — The  mental  development  of  the 
child  must  be  carefully  watched  from  the  beginning.  Just  as  the 
human  embryonal  life  represents  various  upward  stages  of  animal  de- 
velopment, so  the  child's  mind  reproduces  in  miniature  the  earlier  stages 
of  the  growth  of  the  race.  It  is  early  necessary  to  recognize  the  vari- 
ous tendencies  that  manifest  themselves  in  a  growing  child,  so  that  they 
may  be  guided  aright.  It  must  be  remembered  that  the  child  exhibits 
the  elemental  human  forces  and  instincts.  Just  as  the  emotions  are 
developed  in  the  race  before  the  reason,  so  it  is  with  children,  who  can 
be  moved  by  their  sympathies  long  before  they  can  be  influenced  by 
their  intellect.  Love  is  a  surer  guide  for  them  than  reason.  This  is 
the  secret  of  success  of  many  mothers  and  of  some  teachers.  The 
most  lasting  impressions  of  childhood  come  through  the  feelings. 

At  the  end  of  infancy,  and  during  early  childhood,  the  imitative 
faculties  are  especially  dominant.  The  acts  of  older  children,  of  adults, 
and  even  of  animals  are  faithfully  copied  without  much  idea  of  their 
significance.  Up  to  the  age  of  seven  years  much  of  the  training  and 
education  of  the  child  must  come  from  imitation.  Before  this  age 
nearly  all  the  pla3ing  of  children  is  imitative,  shown  by  the  delight 
in  toys  representing  articles  in  real  life,  but  after  this,  especially  in 
boys,  the  games  take  on  a  more  competitive  form  involving  muscular 
exercise. 

There  exists  in  some  children  a  touch  of  barbarism  that  is  merely 
an  evidence  of  underdevelopment.  Apparent  cruelty,  shown  in  a 
callousness  to  suffering,  is  sometimes  seen,  but  this  is  rather  due  to  a 
lack  of  experience  as  to  the  meaning  of  pain  than  to  defective  moral 
sensibilities.  The  conduct  of  the  child  is  largely  influenced  by  the  tone 
and  temper  of  those  around  him,  in  the  intellectual  as  well  as  in  the 
moral  sphere.  A  cultivated  home  will  do  more  for  the  proper  devel- 
opment of  the  child  than  the  formal  education  of  the  finest  schools. 

Adolescence. — The  beginning  of  this  period  is  a  most  interesting 
and  critical  time  for  the  child.     Up  to  this  time,  as  already  noted,  the 


40.  DISEASES  OF  CHILDREN. 

child  has  lived  the  race  life,  but  he  now  begins  to  develop  individual 
characteristics,  and  family  traits  come  out  more  strongly.  There  is  a 
rapid  growth  of  all  parts  of  the  body,  especially  marked  in  the  reproduc- 
tive organs  and  the  heart  and  lungs,  with  increase  in  blood-pressure  and 
in  general  glandular  activity.  The  appearance  of  hair  on  the  pubes 
is  considered  characteristic  of  the  period.  The  peculiarities  of  sex 
now  begin  to  manifest  themselves;  boys  and  girls  cease  to  mingle  in 
such  an  indiscriminate  way  as  in  earlier  childhood.  Up  to  twelve 
years  there  need  not  be  much  differentiation  of  the  sexes,  but  after 
this  they  must  be  separately  considered.  Vague  aspirations  and  a 
general  restlessness  show  the  stirring  of  new  life  in  the  child's  mind. 
Both  the  emotional  nature  and  the  imagination  become  very  active. 
If  any  trait  is  entirely  absent  at  this  time  it  is  not  apt  to  be  seen  later 
in  life. 

As  growth  and  development  are  so  rapid  during  adolescence, 
nothing  must  be  allowed  to  conflict  with  the  physical  nature  at  this 
time.  Overstrain  in  school  must  be  guarded  against.  It  has  been 
proven  from  examinations  of  many  school  children  that,  as  a  rule, 
the  heaviest  and  tallest,  or  those  with  the  best  physique,  stand  highest 
in  their  classes.  Hence  if  a  child  is  poorly  nourished  or  undeveloped, 
the  best  thing,  even  for  his  intellectual  growth,  is  to  focus  attention  on 
his  body  for  a  time  and  let  his  mind  be  temporarily  neglected.  Appar- 
ent stupidity  or  bad  mentality  in  school  children  is  often  the  result 
of  physical  causes  that  may  and  should  be  removed.  Deafness,  defect- 
ive eyesight,  enlarged  tonsils  and  adenoids,  and  poor  nutrition  from 
lack  of  proper  food  may  be  especially  mentioned  in  this  connection. 


SECTION  III. 
THE  EXAMINATION  OF  THE  SICK  CHILD. 


CHAPTER  VL 
THE  EXAMINATION  OF  THE  SICK  CHILD. 

If  the  physician  unaccustomed  to  the  care  of  children  will  first 
learn  what  to  expect  to  find  in  the  normal  child,  he  will  better  appre- 
ciate the  variations  in  disease.  He  must  first  of  all  learn  that  a  proper 
examination  will  take  time,  and  that  a  hurried  examination  often  leads 
to  grievous  errors.  Having  once  made  up  his  mind  to  be  systematic, 
thorough,  and  painstaking,  the  bugbear  of  pediatric  practice  will  begin 
to  disappear,  and  diagnoses  will  be  made  where  formerly  there  was  dis- 
appointment and  confusion.  The  younger  the  infant  or  child,  the  greater 
are  the  peculiarities  from  the  adult  type  in  its  relation  to  disease. 

History. — If  possible  obtain  the  anamnesis  outside  of  the  nursery. 
It  should  preferably  be  obtained  from  the  mother  or  attendant  who 
has  been  in  closest  attendance  upon  the  child.  First — elicit  a  natural 
stor}'  as  to  the  change  from  the  healthy  child  to  the  sick  one.  If  digres- 
sions are  made  they  can  be  guided  back  to  the  proper  channels.  This 
will  give  a  clue  to  the  nature  of  the  illness,  and  the  further  questions 
will  be  modified  considerably  thereby.  For  example,  if  the  disease 
be  one  of  malnutrition,  most  careful  details  of  previous  feeding  from 
the  time  of  birth  will  be  pertinent,  and  the  dietary  life  traced  to  the 
present  time.  Heredity  and  environment  are  inquired  into,  and 
previous  illnesses  recorded  on  properly  prepared  history  blanks.  The 
accompanying  history  card,  as  suggested  by  Dr.  R.  S.  Haynes,  is  one 
that  is  convenient  to  carry,  and  tends  to  making  recording  systematic 
and  of  value  without  much  waste  of  time  and  energy  in  writing. 

Inspection. — The  child  asleep.  Trained  observation  is  the  most 
valued  asset  of  the  pediatrist.  If  possible,  examine  the  child  while  it 
is  asleep.  Sit  by  its  crib  and  watch  it.  Its  general  posture,  if  quiet 
or  restless  is  to  be  noted.  The  breathing  as  to  its  character  must  like- 
wise be  observed,  and  the  number  of  respirations  per  minute  counted. 

Respirations. 
Newborn,  35  to  45        P'irst  to  second  year,     20  to  25 

First  to  the  second  month,  24  to  36        Second  to  sixth  year,     20  to  23 
Second  to  the  sixth  month,  20  to  32        Sixth  to  twelfth  year,    18  to  20 

41 


42 


DISEASES  OF  CHILDREN. 


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THE  EXAMINATION  OF  THE  SICK  CHILD.  43 

The  respirations  may  be  counted  by  the  hand  on  the  abdomen  or 
by  observation  alone. 

If  the  neck  and  chest  can  be  exposed  without  waking  the  child, 
additional  information  is  gained  by  observing  the  effect  of  the  respira- 
tions on  the  supraclavicular  and  suprasternal  spaces. 

Mouth  breathing  is  easily  detected  in  sleep,  and  the  half-closed 
eyelids  are  indications  of  the  weakened  state.  The  pulse  may  now  be 
obtained  without  awakening  the  child  with  a  little  care,  and  is  a  more 
reliable  guide  than  when  influenced  by  fright. 

If  there  is  gastrointestinal  disturbance  inspect  the  last  soiled 
napkin. 

The  Child  Awake. — Enter  the  room  without  apparently  taking 
much  notice  of  the  patient;  a  cheery  word  of  greeting  and  an  interest 
in  his  favorite  toy  will  often  be  sufficient  to  disarm  suspicion  and  win 
a  friend.     Now  have  the  patient  entirely  undressed. 

In  the  case  of  an  infant  it  is  best  examined  on  a  table  in  a  good 
white  light;  if  a  child,  allow  it  to  sit  up.  (If  you  wish  a  child  to  cry  at 
once  make  it  lie  down.)  If  the  infant  is  crying,  much  valuable  informa- 
tion is  obtained  if  this  is  properly  interpreted.  (See  section  on  signs 
of  illness,  p.  57.) 

First  begin  your  inspection  as  to  general  development,  muscula- 
ture, emaciation,  and  the  condition  of  the  skin,  as  these  factors  will 
influence  or  modify  local  changes  seen  elsewhere.  Beginning  at  the 
head,  note  any  abnormalities  in  detail,  i.e.,  as  to  its  size,  shape,  hair, 
eyes,  eyelids,  pupils,  nose,  mouth,  gums,  teeth,  etc. 

The  significance  of  abnormal  conditions  as  seen  here  are  given 
in  the  suggestive  diagnostic  key,  which  see  (p.  81).  Note  the  contour 
of  the  neck,  the  presence  of  enlarged  lymph-glands,  the  spaces  above 
the  clavicles,  the  chest  itself,  if  well  formed,  or  if  showing  any  bony 
changes;  whether  there  is  a  visible  apex  beat  or  a  thrill  over  the  pre- 
cordium;  the  movements  of  the  upper  extremity,  if  natural,  or  if 
there  is  any  paralysis;  the  finger-tips  may  give  valuable  information 
as  to  circulatory  or  pulmonary  involvement;  the  abdomen  if  distended 
or  sunken;  the  external  genitals  for  abnormal  formation  or  dis- 
charge. The  lower  extremities  are  compared  to  the  upper  for  devel- 
opment, bony  changes  and  mobility.  The  infant  may  now  be  turned 
over  and  the  back  of  the  head,  spine,  and  rectum  examined. 

The  temperature  should  always  be  taken  in  the  rectum.  The 
best  plan  with  an  infant  is  to  have  it  lying  face  down  across  the  lap 
of  the  nurse.  An  older  child  is  least  annoyed  by  the  procedure  if  the 
thermometer  is  inserted  while  the  patient  is  lying  on  the  side.  It 
should  be  pushed  past  the  sphincter  and  remain  in  the  rectum  for 


44 


DISEASES  OF  CHILDREN. 


three  minutes.  The  range  in  the  normal  infant  varies  from  98.8°  to 
100.2°  F.  Premature  infants  quite  constantly  have  a  slightly  subnor- 
mal temperature.  Daily  variation  of  several  tenths  of  a  degree  are 
noted.     The  average  temperature  in  early  infancy  is  99°  F. 

Palpation. — This  is  more  readily  and  satisfactorily  accomplished 
if  both  hands  are  used. 

Beginning  at  the  head,  the  right  hand  palpates  the  right  side  of 
the  body  and  the  left  hand  simultaneously  palpates  the  left  side.  The 
contour  of  the  head  and  the  fontanels  are  thus  easily  ascertained. 
Craniotabes,  if  present,  will  not  escape  attention.     Any  glands  in  the 


Fig.  11. — Method  of  palpating  liver  and  spleen. 


occipital  region  are  palpated  and  noted  if  enlarged.  The  lower  eyelids 
are  pulled  down  by  the  fingers  and  the  mucous  membrane  examined. 
Slight  pressure  on  the  chin  will  afford  an  inspection  of  the  lips,  teeth, 
and  tongue;  the  examination  of  the  throat  being  left  for  the  final 
procedure  (p.  343).  The  hands  are  now  passed  over  the  neck  to 
find  any  abnormalities  in  the  anterior  group  of  glands.  Next  the 
shoulder-joints  and  the  axillae  are  explored;  at  the  same  time  the 
musculature  will  be  estimated  to  aid  in  establishing  the  degree  of 
physical  development.  The  epitrochlear  glands  should  not  be  for- 
gotten in  the  examination.  The  hands  of  the  patient  are  palpated  for 
temperature,  irregularities,  or  clubbing.  The  pulse  is  best  counted 
when  the  child  is  asleep.  The  carotid  or  temporal  pulse  may  be  used 
if  the  wrist  is  not  exposed. 


THE  EXAMINATION  OF  THE  SICK  CHILD. 


45 


In  extremely  weak  infants  the  count  is  taken  of  the  heart  beats  at 
the  apex  by  using  a  stethoscope. 
The  pulse  varies  from: 

120  to  140-in  the  new-born. 
[  110  in  the  first  year, 
and  averages  |  100  in  the  second  year. 

[    90  in  the  fifth  to  the  eighth  year. 
If  the  child  is  irritated,  crying,  or  in  pain,  the  pulse  rate  will  be 
accelerated,  and  a  note  should  be  made  of  this  circumstance.     The 
force  and  character  of  the  pulse  are  of  as  much  importance  as  its 
frequency. 


Fig.  12.^ — Method  of  eliciting  Kernig's  sign. 


The  apex  beat  on  the  chest  wall  may  be  located,  or  a  thrill  felt 
in  certain  valvular  diseases,  and  occasionally  tactile  fremitus  will  be  an 
aid  in  diagnosis.  Bony  rachitic  changes  as  the  rickety  rosary  or 
Harrison's  groove  are  identified  by  the  examination  with  the  hands. 

The  right  hand  on  the  abdomen  feels  for  the  lower  border  of  the 
liver,  while  the  left  may  palpate  the  spleen.  If  this  is  palpable  in  a 
child,  it  is  said  to  be  enlarged.  The  liver  in  infants  when  in  the  prone 
position  is  normally  about  one  inch  below  the  free  border  of  the  ribs. 
In  the  erect  position  in  the  infant  it  may  touch  the  crest  of  the  ilium. 
Tumors  in  the  abdomen  and  an  enlarged  kidney  as  in  pyelonephrosis 
can  be  palpated. 


46 


DISEASES  OF  CHILDREN. 


The  hip-joints  and  the  knee-joints  are  examined  for  mobility. 
Pain,  if  eUcited  over  the  tibia,  may  assist  in  establishing  the  diagnosis 
of  scurvy.  The  ankle  and  feet  are  examined  for  signs  of  edema  and 
fiat-foot.  The  lower  extremities  are  approximated,  and  any  abnor- 
malities in  outline  such  as  knock-knee  or  bow-legs  will  then  be  readily 
appreciated. 

The  child  is  now  induced  to  walk,  and  if  postural  defects  warrant 
it  a  detailed  examination  of  the  spine  for  scoliosis  or  Pott's  disease  is 
made. 


K 

F 

T^^^^^^H 

E 

3 

W 

:1 

Fig.  13. — Correct  position  of  holding  an  infant  for  auscultation. 


The  patellar  reflex  may  be  tested  by  raising  the  thigh  from  the 
table  and  allowing  the  leg  to  hang  limply.  A  smart  tap  over  the  ten- 
don below  the  patella  should  elicit  a  ready  response.  In  older  children 
it  may  be  necessary  to  distract  their  attention  by  asking  them  to  look 
at  the  ceiling  or  pull  their  interlocked  fingers  apart  while  the  test  is 
being  made. 

Kernig's  sign,  or  the  inability  to  easily  extend  the  leg  after  flexion 
on  the  thigh,  is  a  valuable  sign  of  meningeal  irritation,  and  this  test 
should  be  made  if  there  is  any  suspicion  of  meningeal  or  cerebral 
involvement. 


THE  EXAMINATION  OF  THE  SICK  CHILD.  47 

The  Babinski  reflex  or  the  hyperextension  of  the  great  toe  and 
a  flexion  of  the  remaining  toes,  is  elicited  when  the  plantar  surface  of 
the  foot  is  irritated  by  drawing  the  finger-nail  across  it.  This  sign 
is  of  value  only  after  the  second  year  of  life,  since  it  may  be  elicited 
in  perfectly  normal  infants.  Rectal  examination  should  be  made  if 
abdominal  conditions  warrant  or  need  further  corroboration. 

Auscultation. — This  should  preferably  follow  palpation  or  some- 
times, if  expedient,  the  inspection.  Infants  should  be  held  in  the 
arms  of  the  mother  or  nurse,  against  her  left  shoulder  with  the  in- 
fant's back  to  the  examiner,  as  illustrated  in  Fig.  13. 

A  stethoscope  with  a  small  bell  is  quite  necessary,  as  the  ear 
cannot  advantageously  be  placed,  for  example,  in  the  axilla  of  an 
infant.     Children    are    best    examined   seated    upon    a   table.     The 


nOBEi^j 


Fig.  14. — Pisek's  reversible  stethoscope. 

stethoscope  is  alternately  passed  from  side  to  side  in  a  line  parallel 
to  the  spine,  then  the  infrascapular  region  is  auscultated,  then  in  the 
axillary  line  on  either  side,  beginning  well  up  in  the  axilla,  with  the 
arms  raised  above  the  head. 

The  front  of  the  chest  is  gone  over  in  a  similar  manner.  The 
examiner  should  recollect  that  the  lungs  in  an  infant  on  the  left  side 
posteriorly  reach  to  the  eleventh  rib;  on  the  right  side  posteriorly, 
to  the  lower  border  of  the  ninth  rib.  In  front,  on  the  right  side  to  the 
fourth  or  fifth  rib  and  on  the  left  side  to  the  ninth  or  tenth  rib. 

Auscultation  of  the  heart  sounds  is  made  at  the  apex,  at  the  base, 
and  at  the  second  right  intercostal  space;  if  any  murmurs  are  present 
they  are  traced  along  the  lines  of  intensity. 

The  examiner  must  accustom  himself  to  pick  out  the  normal 
breath  sounds  while  the  child  is  crjdng.  After  he  becomes  expert  he 
will  almost  prefer  that  the  child  cries  while  he  is  auscultating.  So- 
called  puerile  breathing,  that  is,  exaggerated  normal  vesicular  breath- 
ing, is  to  be  expected. 

It  must  further  be  recollected  that  the  chest  wall  is  thin,  and  the 
sounds  within  are  therefore  more  readily  transmitted  to  the  ear. 

Percussion. — This  should  be  accomplished  with  a  sudden  fight 
tap  because  of  the  thin  wall  and  the  elasticity  of  the  ribs.  Percuss 
alternately  from  side  to  side,  preferably  first  over  the  dorsum  of  the 


48  DISEASES  OF  CHILDREN. 

chest,  then  the  anterior  surface  of  the  lungs,  and  finally  the  area  of  the 
heart  may  be  mapped  out. 

To  do  this  begin  your  percussion  near  the  clavicle  and  percuss 
downward  until  the  note  changes  at  the  base  of  the  heart.  Make 
your  line  here  with  a  flesh  pencil.  The  right  border  of  the  heart  is 
found  by  beginning  the  percussion  well  to  the  right  of  the  sternum 
and  mapping  out  this  border  to  the  apex.  The  left  side  is  similarly 
found,  by  beginning  the  percussion  from  the  axillary  side.  The  apex 
beat  may  be  located  both  by  palpation  and  auscultation. 

The  area  of  absolute  heart  dullness  is  relatively  small  in  infants,  but 
the  fact  that  the  lungs  do  not  overlap  the  heart  as  they  do  in  the  adult 
should  not  be  forgotten  in  percussing  for  the  relative  dullness.  Per- 
cussion over  the  abdomen  may  be  made,  to  obtain  the  lower  border 
of  the  stomach,  or  a  distended  colon,  for  free  fluid  in  the  abdomen, 
a  distended  urinary  bladder,  partial  intestinal  collapse,  or  appendicial 
abscess.  In  cerebral  cases  in  which  fluid  is  suspected  in  the  ventricles 
Macewen's  sign  should  be  sought  for;  this  consists  of  a  tympanitic 
note  heard  over  the  parietal  area  when  the  ventricles  are  distended 
as  in  hydrocephalus  or  in  certain  cases  of  meningitis. 

Mensuration. — The  weight  should  be  recorded  in  infants  once 
or  twice  a  week,  in  older  children,  each  time  they  are  brought  to  the 
physician  so  that  he  may  judge  of  the  progress  of  their  general  develop- 
ment. For  infants  a  weight  chart,  such  as  has  been  devised  by 
Dr.  W.  L.  Carr,  is  useful  (Fig.  15).  The  standing  height  should  be 
occasionally  taken  and  compared  to  the  weight.  (See  diagrammatic 
table,  page  32,  for  normal  relations.)  The  circumference  of  the  head 
and  chest  and  their  relations  to  each  other  give  valuable  data  as  to 
disease  conditions  or  to  defects  in  physical  development.  The  tape 
used  should  be  made  of  nonstretchable  linen  or  steel.  If  on  auscul- 
tation or  percussion  signs  of  fluid  in  the  chest  have  been  obtained,  the 
tape  measure  may  show  the  affected  side  of  the  chest  to  be  greater 
than  the  other.  Mensuration  of  an  atropic  extremity  or  muscle 
groups  are  made  in  cases  of  infantile  paralysis  or  in  the  dystrophies. 

Rectal  Examination. — -The  rectum  and  sacrum  in  infants  and 
children  is  almost  straight,  and  because  of  the  shallow  pelvis,  the  so- 
called  "pelvic  organs"  of  the  adult  are  found  to  be  partly  or  wholly 
abdominal  in  the  infant  and  child. 

The  index-finger  in  the  case  of  the  child,  or  the  little  finger  in  the 
infant,  can  be  used,  and  with  the  help  of  the  other  hand,  bimanual 
examination  is  easily  made.  The  abdominal  wall  is  usually  thin  and 
offers  little  or  no  resistance  to  the  palpating  finger.  As  a  rule,  no  anes- 
thetic is  required,  as  the  sphincter  relaxes  easily  and  the  discomfort 


PLATE    IV. 


Illustrating  topographical  anatomy  of  the  lungs  and  the  lobes,  also 
position  of  the  heart  and  relations  of  the  bronchi. 


PLATE  V. 


Showing  position  of  lower  border  of  the  lungs  and  the  position  of  the  kidneys. 


THE  EXAMINATION  OF  THE  SICK  CHILD. 


49 


is  temporary.  The  child  should  lie  on  its  back  with  hips  elevated 
and  the  thighs  flexed  on  the  abdomen.  The  examiner  standing  on  the 
right  side  of  the  patient  explores  with  the  well-lubricated  finger  of  the 
right  hand,  using  the  left  hand  for  abdominal  palpation.     The  opera- 


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tion  is  reversed  for  the  left  side  of  the  body.     Any  abnormalities, 

new-growths,  or  diseased  conditions  of  the  structures  and  viscera  in 

the  lower  abdomen  can  then  be  palpated  and  much  information  gained. 

In  cases  of  tuberculous  peritonitis  the  abnormal  omental  thick- 

4 


50  DISEASES  OF  CHILDREN. 

ening  and  the  matting  of  the  intestines  can  often  well  be  made  out, 
the  diagnosis  thus  confirmed,  and  the  prognosis  made  more  definite. 
Enlarged  mesenteric  and  retroperitoneal  glands  are  palpable  by  a 
sweeping  motion  of  the  introduced  finger  without  the  necessity  of 
changing  hands. 

Intraabdominal  sarcomata  can  be  quite  definitely  located;  calculi 
in  the  bladder  or  ureters  palpated,  malformations  of  the  kidneys  or 
enlarged  kidneys,  as  in  hydro-,  or  pyonephrosis  may  be  distinguished. 

Therefore,  in  an  abdominal  case  where  the  diagnosis  is  not  abso- 
lutely clear  and  uncomplicated,  the  examiner  should  not  pass  judg- 
ment upon  a  given  case  without  recourse  to  a  thorough  examination 
through  the  rectum. 


CHAPTER  VII. 
SPECIAL  EXAMINATIONS. 

A  culture  and  a  smear  should  be  made  for  examination  if  the 
throat,  e.  g.,  shows  a  suspicious  membrane  or  if  there  is  a  serosanguino- 
lent  discharge  from  the  nares.  A  sterile  cotton  applicator  is  swabbed 
over  the  area  and  gently  wiped  over  the  culture  medium  or  upon  a  clean 
glass  slide.  A  purulent  secretion  from  the  eyes  may  demonstrate 
on  smear  the  presence  of  the  Koch-Weeks  bacillus  or  the  gonococcus  of 
Neisser.  A  similar  test  of  a  vaginal  or  urethral  discharge  will  be 
necessary  to  determine  the  character  of  the  contagion  and  the 
necessary  precautionary  measures. 

Sputum  for  examination  can  be  obtained  in  younger  children  by 
means  of  a  laryngeal  applicator  passed  down  the  epiglottis,  or  by  pass- 
ing a  catheter  partly  into  the  esophagus. 

Fluid  obtained  by  lumbar  puncture  should  be  collected  into 
sterile  tubes  and  allowed  to  stand  until  a  coagulum  forms.  This  is 
taken  for  examination.  Centrifuging  is  then  done,  and  a  further  search 
made  for  the  causative  agent  and  cell  content.  (For  technic,  see  p.  52.) 
A  drop  or  two  should  be  allowed  to  flow  over  a  culture  medium  for  in- 
cubation and  possible  growth. 

Aspirated  fluid  from  the  chest  when  slightly  clouded  is  microscop- 
ically examined  for  the  presence  of  pus-cells,  and  operative  interfer- 
ence is  often  based  on  their  numerical  estimate.    (Fortechnic,  seep.  54.) 

Blood  is  best  taken  from  the  lobe  of  the  ear  or  finger-tip.  The 
part  is  well  cleansed  and  the  first  drop  obtained  wiped  away.  No 
undue  pressure  should  be  used  to  obtain  a  blood  flow.  The  pipette 
or  the  Tallquist  scale  is  used  for  the  hemoglobin  estimation.  A  thin 
smear  is  made  for  malarial  organisms.  For  the  typhoid  test  (Widal) 
three  droplets  about  the  size  of  the  head  of  a  black  pin  are  collected 
at  different  points  on  the  glass  slide.  The  differential  count  is  made 
from  a  thin  smear  and  stained.  For  details  and  technic  see  a  labora- 
tory guide  to  diagnosis. 

The  A'-rays  are  of  late  assuming  a  greater  importance  in  pediatric 
practice.  Foreign  bodies  swallowed  or  aspirated,  fractures  and  dis- 
locations, bone  changes  and  tumors,  estimation  of  anatomic  age,  dis- 
placed viscera,  consolidations  and  exudations  are  conditions  in  which 

51 


52 


DISEASES  OF  CHILDREN. 


we  can  obtain  valuable  aid.     Short  exposures  should  be  made  with  the 
best  tubes.     An  anesthetic  is  sometimes  necessary  for  unruly  children. 

Technic  for  Subdural  or  Lumbar  Puncture. 

One  of  two  positions  may  be  selected:  the  sitting  posture,  or  the 
child  may  be  placed  on  its  side  with  the  spinal  column  well  flexed. . 
Cleanse  the  lower  lumbar  area  until   the   parts   are  surgically  clean. 
The  operator,   who  has  thoroughly  cleansed  his  hands  then  takes 
the  sterilized  needle  in  his  right  hand,  as  one  holds  a  pencil  in  writing, 


Fig.  16. — Method  of  performing  subdural  or  lumbar  puncture. 


and  inserts  the  same  at  right  angles  to  the  body  through  the  inter- 
vertebral disk  between  the  third  and  fourth  lumbar  vertebrae  (see  Plate 
V).  This  point  is  conveniently  located  by  placing  the  index-  and 
third  fingers  of  the  left  hand  on  the  highest  points  of  the  respective 
iliac  crests,  the  middle  finger  being  placed  on  the  vertebral  spine  which 
is  on  the  same  level  as  the  crests  above  determined.  This  is  the  third 
lumbar  spine,  and  the  point  of  election  is  midway  between  this  spine 
and  the  one  immediately  below  it.     The  needle  meets  with  only  carti- 


PLATE  I. 


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SPECIAL  EXAMINATIONS.  53 

laginous  resistance  if  properly  inserted,  and  should  be  introduced  about 
three-quarters  of  an  inch.  If  bony  resistance  is  encountered,  with- 
draw slightly  (not  entirely)  and  change  somewhat  the  angle  of  inser- 
tion. If  the  spinal  canal  is  entered  a  free  flow  of  fluid  follows;  then 
allow  the  fluid  to  escape  into  a  sterile  tube.  At  the  same  time  collect 
two  or  three  drops  in  a  culture  tube  of  blood  serum.  When  15  c.c. 
have  been  collected  quickly  withdraw  the  needle  and  seal  the  punc- 
ture wound  with  cotton  and  collodion. 

Estimation  of  Hemoglobin. 

{Tallquist  Method.) 

After  puncturing  the  tip  of  the  finger  or  lobe  of  the  ear,  allow  the 
filter-paper  to  slowly  absorb  the  drop  until  an  area  the  size  of  a 
dime  has  accumulated.  Allow  to  stand  until  the  humid  gloss  is  lost, 
then  compare  with  the  scale  provided  pressing  the  color  scale  firmly 
against  the  blood  stain,  using  daylight  but  not  direct  sunlight  for  il- 
lumination. This  method  while  a  ready  and  inexpensive  one  compares 
very  favorably  with  the  Dare  hemoglobinometer,  above  50  per  cent. 

Test  for  Indican. 

The  simplest  and  probably  the  most  accurate  test  for  indican  in 
urine  is  performed  as  follows :  to  a  clean  test-tube  add  four  to  six  drops 
of  a  1  per  cent,  solution  of  potassium  permanganate,  then  1  or  2  c.c. 
of  chloroform,  then  10  c.c.  of  concentrated  hydrochloric  acid  C.  P., 
and  lastly  10  c.c.  of  urine.  Invert  the  test-tube  two  or  three  times  to 
thoroughly  mix  and  allow  to  stand  five  minutes.  The  ethereal  sul- 
phates in  the  urine  are  broken  down  by  the  hydrochloric  acid  and 
are  oxidized  by  the  potassium  permanganate  to  indigo  which  is  dis- 
solved by  the  chloroform,  giving  a  deep  blue  color,  the  intensity 
of  which  when  compared  with  the  color  scale  (Plate  I)  deter- 
mines the  extent  of  the  putrefactive  changes  occurring  in  the 
intestine. 

Transudates  and  Exudates. 

Rivalta  has  recently  perfected  a  test  for  accurately  distinguishing 
between  transudates  and  exudates. 

Add  2  drops  of  acid  acetic  (glacial)  to  100  c.c.  of  water  to  make 
the  test  solution.  Allow  the  exudate,  a  drop  at  a  time,  to  make  its  way 
down  through  the  dilute  acid  medium  and  it  will  leave  a  bluish  trail 
in  the  water  like  a  puff  of  cigarette  smoke,  each  drop  leaving  a  separate 


54  DISEASES  OF  CHILDREN. 

trail.     The  fluid  remains  clear  and  unaltered  if  the  added  drop  be  that 
of  a  transudate. 

Technic  for  Aspiration  of  Pleural  Cavity. 

Sterilize  a  needle  and  clean  the  chest  wall  over  the  site  of  election, 
in  all  cases  observing  strict  surgical  asepsis. 

Place  the  child  in  a  sitting  posture  with  both  arms  drawn  well 
forward,  then  holding  the  needle  at  a  right  angle  to  the  body,  puncture 
in  the  midscapular  or  in  the  posterior  axillary  line  (preferably  the 
former),  the  point  of  election  being  the  interspace  just  below  the 
angle  of  the  scapula.  Insert  the  needle  about  three-quarters  of  an 
inch.  From  the  fluid  a  culture  is  made  and  the  remainder  is  collected 
in  an  empty  sterile  tube  for  further  examination.  Seal  the  puncture 
wound  with  cotton  and  collodion. 

Tuberculin  Tests  (also  see  p.  324). 

One  of  three  tests  may  now  be  selected  for  use  in  suspected  tuber- 
culous children.  The  skin  test  was  superseded  by  the  eye  test  and 
inunction  test,  but  to-day  it  has  the  greatest  number  of  advocates, 
since  it  is  the  most  reliable  and  at  the  same  time  least  annoying  to 
the  patient. 

Skin  or  Von  Pirquet  Test. 

This  is  made  by  scarifying  three  small  areas  on  the  arm,  as  for 
vaccination,  and  inoculating  the  central  one  with  a  drop  of  Koch's 
old  tuberculin  (obtainable  in  the  market),  using  the  upper  and  lower 
areas  as  controls.  In  from  twelve  to  forty-eight  hours  (occasionally 
even  longer)  a  reaction  will  be  observed  in  tuberculous  individuals. 
At  first  a  reddened  blush  appears  which  soon  becomes  inflamed  and 
resembles  the  first  stages  of  a  successful  vaccination.  The  controls 
should  show  no  reaction.  In  advanced  cases  the  reaction  usually 
fails,  due  to  the  presence  of  numerous  antibodies  in  the  blood  of 
the  child. 

The  Calmette  or  Eye  Test. 

In  selected  cases  in  which  we  are  positive  that  the  eye  is  normal, 
one  drop  of  a  one  per  cent,  solution  of  tuberculin  for  older  children 
and  a  one-half  per  cent,  for  infants,  is  dropped  on  the  lower  lid  of  one 
eye  and  the  eyelid  held  down  for  a  moment  before  allowing  the  eye 
to  close;  the  closure  should  not  be  spasmodic,  but  gentle;  it  is  better  to 
gently  massage  the  eyelids  over  the  eyeball  for  a  moment. 


The  ocular,  percutaneous  and  cutaneous  tests,     (a)  ocular  reaction;  (b) 
inunction  or  Moro  reaction;  (c)  cutaneous  or  Von  Pirquet  reaction. 


SPECIAL  EXAMINATIONS.  55 

A  positive  reaction  is  indicated  by  a  feeling  of  annoyance  in  the 
eye  which  ensues  in  from  six  to  twenty-four  hours,  or  even  after  two 
days.  The  palpebral  or  ocular  conjunctiva  becomes  injected,  later  the 
caruncle  is  swollen,  and,  in  intense  reactions,  an  exudate  is  observed. 
The  patient  complains  of  having  a  "  cold  in  the  eye."  The  symptoms 
soon  diminish,  so  that  in  four  to  five  days  the  eye  is  quite  normal 
again. 

The  indiscriminate  use  of  this  test  has  led  to  reports  of  corneal 
ulceration.  The  severity  of  the  reaction  is  no  criterion  for  the  in- 
tensity of  the  infection.  Severe  reactions  may  follow  in  incipient 
cases.  As  in  the  skin  test,  active  and  latent  cases  will  react,  but  those 
far  advanced  may  give  a  negative  test.  It  should  be  remembered 
that  no  immunity  to  tuberculin  is  produced  by  these  tests;  the  other 
eye  will  react;  a  skin  test  or  inunction  test  can  be  subsequently  made 
in  the  same  individual. 

The  Inunction  or  Moro  Test. 

The  Moro  reaction  is  obtained  by  using  a  50  per  cent,  tuberculin 
and  lanolin  ointment,  and  vigorously  rubbing  a  piece  the  size  of  a 
split  pea  for  a  few  moments  over  the  site  selected;  this  may  be,  for 
example,  the  axillary  or  the  interscapular  region.  A  maculopapular 
eruption  is  produced  in  the  tuberculous  at  the  annointed  area  in  from 
twelve  to  twenty-four  hours.  It  may  persist  for  five  days  to  over  a 
week,  and  in  neurotic  children  may  appear  on  the  opposite  side  of  the 
body.  The  test  is  simple,  easily  performed  and  commends  itself  for 
use  with  intractable  children. 

Thread  Reaction  in  Pyelitis. 

Pf aundler  demonstrated  "  that  a  bouillon  culture  of  bacilli  grown 
on  urine  and  mixed  with  the  blood  serum  of  the  same  patient  will 
produce,  even  when  considerably  diluted,  an  agglutination"  such  as 
occurs  in  other  bacillus  coli  infections. 

The  bacteria  to  be  examined  are  grown  on  agar-agar,  a  twenty- 
four  hour  culture  being  employed.  Three  drops  from  the  (water  of 
condensation)  culture  are  added  to  a  bouillon  tube.  This  emulsion 
is  mixed  with  the  patient's  serum  in  the  proportion  of  one  to  thirty 
or  one  to  fifty,  and  then  examined  in  the  hanging  drop.  After  twenty- 
four  hours  if  the  reaction  is  positive  the  following  appearances  develop : 
"The  small  rods  grow  out  into  delicate  extremely  long  threads  which 
appear  claw-like  and  interwoven,  and  form  lumpy  groups  under  slight 
magnification.     The  groups  are  either  isolated  or  else  are  connected 


56  DISEASES  OF  CHILDREN. 

by  extremely  delicate  filaments.  Between  the  single  filaments  the 
liquid  is  perfectly  free  from  form  element.  The  threads  and  filaments 
do  not  present  the  least  indication  of  mobility.  Under  high  powers 
the  threads  appear  partly  articulated,  granular  and  sometimes  thick- 
ened with  clubs.  The  threads  are  greatest  in  length,  and  the  filaments 
are  densest  in  the  reaction  where  the  serum  dilution  is  the  least." 

To  produce  this  reaction  the  necessary  conditions  are:  "the 
employment  of  a  serum  of  microbes  from  the  same  patient  and  the 
presence  of  fever  during  the  infection  as  an  indication  of  the  general 
disturbances,  the  reaction,  however,  fails  not  only  in  light  cases  of 
brief  duration,  but  in  serious  cases  which  end  in  death." 

The  Wasserman  Test  for  Syphilis. 

This  reaction  has  proven  to  be  of  distinct  value  in  the  diagnosis 
of  suspected  cases  of  syphilis.  It  can  be  used,  however,  only  in  lo- 
calities where  there  is  a  well-equipped  laboratory  which  has  the  spe- 
cial apparatus  required  for  its  performance.  In  spite  of  the  many 
attempts  which  have  been  made  to  simplify  the  test,  it  still  requires 
a  special  training  and  much  time  if  reliable  results  are  to  be  obtained. 

Fox,  in  a  recent  communication  from  which  this  is  freely  drawn, 
describes  the  technic  and  explains  the  principles  upon  which  this  is 
founded.  He  concludes  that  the  reaction  must  be  considered  as  a 
union  taking  place  between  certain  lipoid  substances  and  the  antibodies 
existing  in  syphilitic  blood. 

The  reaction  requires  that  five  substances  be  carefully  secured 
by  following  a  certain  method  and  laboratory  technic: 

(1)  Antigen — made  from  the  liver  of  a  syphilitic  fetus  or  from 
crude  lecithin. 

(2)  Antibody — serum  from  the  patient's  blood. 

(3)  Complement — serum  from  the  blood  of  a  guinea-pig. 

(4)  Hemolytic  amboceptor — inactivated,  standardized  serum 
from  the  blood  of  a  rabbit  previously  injected  with  sheep's  corpuscles. 

(5)  Sheep's  corpuscles. 

These  five  substances  are  added  to  the  serum  of  the  suspected 
patient,  and  also  to  the  serum  of  a  known  positive  and  a  negative  case. 
Ample  controls  are  made  to  insure  that  complete  hemolysis  takes 
place  and  that  neither  the  antigen  nor  the  patient's  serum  does  not 
bind  the  complement. 

Complete  hemolysis  denotes  a  negative  result,  while  inhibited 
hemolysis  is  classed  as  positive  and  graded  according  to  the  degree 
of  intensity  as  strong-positive  or  weak-positive. 


CHAPTER  VIII. 
SIGNS  OF  ILLNESS  IN  INFANCY. 

As  it  is  by  no  means  easy  in  every  case  to  tell  exactly  when  or 
how  an  infant  begins  to  be  ill,  a  close  observation  of  symptoms  and 
their  proper  interpretation  becomes  highly  important.  Slight  causes 
often  produce  very  marked  and  sudden  effects  at  this  time  of  life. 
This  is  explained  b}^  the  active  growth  of  infants  and  especially  by  the 
rapid  development  and  irritability  of  the  nervous  system.  Thus  a 
really  slight  indisposition  may  present  the  appearance  of  severe  dis- 
ease, while  the  converse  of  this  is  sometimes  true,  as  serious  illness  may 
so  blunt  this  delicate  nervous  susceptibility  as  to  cause  the  true 
gravit}^  of  certain  cases  to  be  overlooked.  Attention  may  be  called 
to  various  conditions  that  are  evidences  of  some  disturbance,  and  to 
note  what  they  usually  signify. 

Irritability  of  Temper. — In  the  absence  of  speech,  the  infant 
shows  discomfort  or  suffering  principally  by  cries  and  restlessness.  If 
watched  closely,  it  may  by  certain  signs  indicate  to  some  extent  the 
seat  of  the  trouble.  In  headache,  the  hand  will  be  frequently  raised 
and  held  beside  the  head;  in  earache,  the  hand  will  be  carried  to  the 
ear,  and  often  pull  upon  that  organ;  in  difficult  and  painful  dentition, 
the  fingers  will  be  constantly  inserted  in  the  mouth,  as  if  to  pull  out  the 
cause  of  distress;  irritation  of  the  stomach  and  bowels  may  be  accom- 
panied by  a  continual  rubbing  of  the  nose.  During  an  attack  of  colic, 
the  legs  are  drawn  up  over  the  abdomen,  w^hich  feels  hard,  and  there 
is  likewise  a  writhing  motion  of  the  body.  Crying  is  a  very  constant 
accompaniment  of  all  kinds  of  illness.  Constant,  uninterrupted  cry- 
ing is  usually  caused  b}^  earache,  hunger,  or  thirst.  If,  after  giving 
the  baby  suitable  nourishment  or  a  drink  of  water,  it  still  keeps  up 
a  continuous,  almost  automatic  cry,  there  is  probably  severe  pain  in 
the  ear.  This  may  be  confirmed  by  pressing  in  front  and  behind  this 
organ,  when  the  baby  will  wince.  Where  there  is  some  disease  in  the 
head,  a  sudden,  piercing  cry  is  uttered  at  certain  intervals,  between 
which  there  will  probably  be  no  fretting.  In  pneumonig,,  there  is 
crying  only  during  spells  of  coughing  and  a  short  time  after;  in  pleurisy, 
there  is  likewise  crying  only  during  coughing,  but  it  is  shriller  and 
shows  more  suffering  than  in  pneumonia,  and  is  also  produced  by  mov- 

57 


58  DISEASES  OF  CHILDREN. 

ing  the  child  and  pressing  over  the  affected  side.  Crying  just  before  or 
after  a  movement  of  the  bowels,  with  a  twisting  of  the  pelvis,  gives 
evidence  of  intestinal  pain. 

Where  the  hand  is  tightly  shut,  with  the  thumbs  thrust  deeply 
into  the  palms,  and  the  toes  strongly  bent,  there  is  much  nervous 
irritation,  which  may  eventuate  in  a  convulsion. 

Restless  Sleep. — Much  may  be  learned  by  a  careful  inspection 
of  an  infant  during  sleep.  A  well  child  always  sleeps  quietly,  but, 
when  ill,  sleep  is  fitful  and  sometimes  only  possible  when  the  infant  is 
rocked  or  patted  or  carried  about  in  the  arms.  If  there  is  a  constant 
kicking  off  of  the  bedclothes,  so  that  the  child  will  not  long  keep  covered 
even  in  cold  weather,  it  is  a  pretty  sure  indication  of  rickets.  When 
it  is  impossible  for  a  child  to  sleep  unless  the  head  and  shoulders  are 
raised  high  upon  a  pillow,  there  is  usually  some  disturbance  in  the  ac- 
tion of  the  heart  or  lungs.  If  a  child  sleeps  with  its  mouth  wide  open 
and  the  head  thrown  back,  there  is  enlargement  of  the  tonsils  or  ade- 
noid tissue  at  the  vault  of  the  pharynx  interfering  with  natural  quiet 
breathing  through  the  nose.  A  persistent  boring  of  the  back  of  the 
head  into  the  pillow  points  to  cerebral  irritation.  When  sleeping  with 
half-open  eyes,  there  is  apt  to  be  moderate  pain  present,  and,  if  there 
is  a  constant  movement  of  the  lips,  the  discomfort  is  located  in  the 
gastrointestinal  canal. 

Changes  in  the  Features. — When  illness  is  present,  it  is  quickly 
shown  in  the  countenance  of  the  infant,  which,  during  health,  is  in  a 
condition  of  easy  repose.  In  general,  it  can  be  stated  that  the  upper 
part  of  the  face  is  involved  in  diseases  of  the  head,  the  middle  part  in 
affections  of  the  chest,  and  the  lower  part  in  disturbances  involving  the 
abdominal  organs.  Thus  in  disease  of  the  brain,  the  forehead  and  eye- 
brows will  be  sharply  contracted,  and  the  eyes  sensitive  to  light  with 
various  changes  in  the  pupils.  Puffiness  and  swelling  about  the  eye-lids 
point  to  dropsy,  which  is  usually  caused  by  diseases  of  the  kidneys 
following  scarlet  fever  or  other  infectious  process,  but  occasionally  by 
severe  anemia.  In  pneumonia  and  pleurisy  the  nostrils  are  sharply 
defined,  and  dilate  and  contract  with  the  movements  of  respiration 
which  will  appear  more  or  less  labored.  The  mouth  is  the  feature  most 
affected  in  abdominal  disease,  shown  by  a  drawing  of  the  upper  lip  and 
other  movements  indicating  pain. 

State  of  the  Discharges. — A  careful  examination  of  all  the 
organs  opening  upon  the  surface  of  the  body  must  be  made  to  detect 
any  abnormal  discharges.  The  ears,  eyes,  nose,  mouth,  urinary  and 
rectal  regions  must  thus  be  carefully  inspected. 

The  upright  position  of  the  stomach  during  infancy  renders  vomit- 


SIGNS  OF  ILLNESS  IN  INFANCY.  59 

ing  a  frequent  and  easy  symptom  when  this  organ  is  distended.  In 
such  a  case  there  may  be  a  regurgitation  of  some  sHghtly  curdled  milk 
after  each  feeding.  The  infant  shows  no  distress  from  this  act  and  con- 
tinues in  a  good  condition  of  health;  the  stomach  simply  rejects 
any  excess  of  food  above  that  which  it  can  readily  hold.  But  sudden 
and  profuse  vomiting,  without  any  error  in  diet,  may  constitute  the 
beginning  of  severe  illness,  such  as  scarlet  fever,  diphtheria,  or  some 
brain  disease.  Acute  illness  in  early  life  may  begin  with  vomiting  in 
place  of  the  chill  seen  in  older  subjects.  Vomiting  may  simply  be  a 
sign  of  local  disturbance  in  the  stomach,  as  when  mucus  is  ejected  in 
cases  of  gastric  irritation.  Where  tough  curds  are  vomited  with  the 
milk  very  sour,  there  is  evidence  of  fermentation  of  the  milk  and  an 
overacid  condition  of  the  stomach.  If  this  persists,  the  mouth  will 
become  red  and  sore  from  a  direct  continuity  of  the  irritation. 

Much  can  be  learned  by  investigating  the  number  and  charajrter 
of  the  discharges  from  the  bowel.  During  the  first  two  months  there 
are  usually  three  or  four  stools  in  the  twenty-four  hours,  and  during 
the  first  two  years,  two  stools  a  day  on  an  average.  The  stools  are 
homogeneous,  of  a  soft,  semisolid  consistency,  and  of  yellowish  color. 
In  cases  of  diarrhea  or  inflammation  they  may  be  green,  or  contain 
hard,  lumpy  curds,  or  have  an  admixture  of  mucus  and  blood,  or  be 
of  very  watery  consistency.  Abnormal  stools  will  be  considered  more 
at  length  in  the  section  devoted  to  diarrhea. 

The  urine  is  passed  many  times  in  the  twenty-four  hours,  and  the 
diaper  may  have  to  be  changed  as  often  as  every  hour.  Infants  vary 
in  this,  however,  as  they  may  go  six  or  eight  hours  without  voiding 
urine.  If  twelve  hours  pass  without  it,  a  careful  examination  must 
be  made  in  order  to  reveal  the  cause  of  retention.  In  some  cases  where 
the  urine  is  highly  acid,  it  may  be  expelled  when  a  few  drops  collect 
in  the  bladder,  and,  as  this  amount  quickly  dries  in  the  diaper,  there 
is  no  evidence  from  wetting  that  urine  has  been  passed.  A  dark,  smoke- 
colored  urine  may  indicate  nephritis,  and  thus  be  of  great  significance. 
Scanty  urine,  loaded  with  uric  acid  and  the  urates,  may  leave  a  red 
deposit  upon  the  napkin  simulating  blood. 


CHAPTER  IX. 
GENERAL  THERAPEUTICS. 

Under  this  heading  will  be  described  methods  and  means  of  treat- 
ment that  are  ordinarily  employed  in  pediatric  practice. 

As  these  various  measures  are  used  in  a  number  of  conditions,  it 
is  advisable  to  discuss  them  at  some  length  and  later  refer  to  this 
chapter  when  outlining  the  treatment  for  a  certain  disease. 

Drug  Administration. 

Never  prescribe  a  drug  without  a  good  and  sufficient  reason. 
Prescribe  so  that  the  dose  will  be  small  in  amount  and  as  agreeable  as 
possible.  Heavy  syrupy  mixtures  may  be  agreeable,  but  are  apt  to 
give  rise  to  fermentation  from  excess  of  sugar.  Pills  and  capsules 
are  not  intended  for  children  who  rarely  can  swallow  them.  Pre- 
scriptions should  be  simple  and  if  possible  contain  but  one  or  at  most 
two  drugs.  Powders  made  up  with  sugar  of  milk  are  mixed  with  water 
and  given  from  the  teaspoon.  Tablet  triturates  form  an  easy  and 
accurate  method  of  giving  drugs  (except  nitroglycerin).  If  the  child 
is  unwilling,  the  medication  on  the  spoon  is  quickly  slipped  on  to  the 
tongue  and  the  spoon  held  in  position  well  back  until  swallowing  takes 
place.     In  this  way  the  child  cannot  regurgitate  it. 

Begin  with  small  doses  in  early  life  and  increase  if  the  desired  effect 
is  not  obtained.  Heroic  doses,  however,  may  be  used  in  emergencies 
where  rapid  and  active  stimulation  is  required.  Hypodermatic  in- 
jection of  the  stimulant  is  often  required  to  produce  physiological 
effects. 

The  rule  that  an  infant  up  to  a  year  should  receive  one-twentieth 
of,  and  at  one  year  one-tenth  of  the  adult  dose,  is  to  be  followed  in  the 
majority  of  cases.  The  stimulants,  however,  are  exceptions  to  this 
rule.  At  the  fifth  year  one-fifth,  and  about  the  tenth  year  one-half 
the  adult  dosage  is  usually  to  be  given. 

Castor  oil  should  be  administered  ice  cold  on  a  wet  spoon.  The 
taste  of  quinine  in  solution  may  be  disguised  with  syrup  of  yerba  santa, 
extract  of  licorice  or  syrup  of  wild  cherry,  but  it  is  not  unusual  to  find 
children  who  take  bitter  medication  better  than  adults.  Tasteless 
quinin  in  the  form  of  euquinin,  tannate  of  quinin,  or  saccharated 

60 


GENERAL  THERAPEUTICS. 


61 


quinin  is  now  obtainable.  Sweet  chocolate  disguises  the  taste  ad- 
mirably. Opium  or  its  derivates,  with  the  exception  of  codein,  are 
to  be  largely  avoided.  The  coal-tar  derivatives,  combined  with  caffein 
are  used  at  times  to  control  pain.  They  should  be  given  in  small 
doses,  and  not  as  a  routine  measure  for  the  control  of  pyrexia. 

The  drugs  or  preparations  of  drugs  most  frequently  used  internally 
with  the  greatest  advantage  in  pediatric  practice  are: 


(1) 
Calomel. 
Castor  oil. 
Fowler's  solution. 
Basham's  mixture. 
Bismuth  subnitrate. 
Bromids. 
Cascara  sagrada. 
Cod-liver  oil. 
Strychnin  sulphate. 
Digitalis. 

Sweet  spirits  of  niter. 
Syrup  of  iodid  of  iron. 
Tincture  of  nux  vomica. 
Salicylates 
Alcohol. 

Potassium  iodid. 
Ammonium  compounds. 


(2) 
Atropin. 
Camphor. 
Nitroglycerin. 
Chloral  hydrate. 
Codein  phosphate. 
Dover's  powder. 
Hexamethylenamin . 
Hydrochloric  acid. 
Liquorice  powder. 
Phenacetin. 
Rhubarb. 
Salol. 

Iron  compounds. 
Asafetida. 
Santonin. 
Aspidium. 
Ipecac. 


TABLE  OF  AVERAGE  DOSAGE. 


Drug 


Dose, 

Age 

6  mos. 


Dose, 
Age 

2  yrs. 


Dcse, 

Age 

3  to  5  yrs. 


I       Dose, 
Dose,      I  Maximum 
F  equency  [  in  24  hrs. 
I  Age  5  yrs. 


q.  2-4  hrs.    ix^    2-6 
q.  2-4  hrs.    gr.  12-24 
q.  2-4  hrs.    gr.  12-24 


Aconite  Tinct.  (10  per  cent.)  gtt.  \  gtt.  J  I  gtt.  1-2 

Ammonium  Chloride gr.  i  gr.  ^  gr.  1-2 

Ammonium  Carbonate  .  .  .  .  gr.  j  gr.  i  gr.  1-2 

Ammonium  Acetate  Sol.  I 

(Spirit  Mindererus) gtt.  10  dr.  \  \  dr.  1-2 

Ammonium  Aromatic  Spts.  gtt.  3  gtt.  5  gtt.  10 

(Liq.  Ammonii  Anisatis) .  gtt.  1-2      ;  gtt.  3  gtt.  5 

Antipyrin     gr.  i  gr.  1  gr.  2-3 

Antitoxin. 
Diphtheritic 

Immunization 500  units  500  to  500  to          ]  Repeat     \ 

1,000  units  1,000  units   |  or  double;  to  effect 

:  i  I  I  the  dose 

Pharyngeal  Type    3,000  units  5,000  units  5,000  units!  [in  12  hrs. 

Laryngeal  Type 10,000  10,000  10,000 

units  units  units 

Arsenic  i 

Fowler's  Sol.   (Liq.   Pot.  | 

Arsenitis) ni  ^  ir^  1  '  n|  2-3 

Arsenious  Acid   gr.  4o  gr-  sstt  gr.  siu 


q.  4  hrs.  dr.  3-6 

q.  1-4  hrs.  dr.  ^-1^ 

q.  1-4  hrs.  gtt.30-dr.l 

t.i.d.  gr.  5-10 


if    neces- 
sary. 


t.i.d 
t.i.d. 


TT|  10,  or 
to  effect 


gr- 


62  DISEASES  OF  CHILDREN. 

TABLE  OF  AVERAGE  DOSAGE.— Continued. 


Drug 


Dose, 

Age 

6  mos. 


Dose, 

Age 

2  yrs. 


Dose, 

Age 

3  to  5  yrs. 


Dose, 
Frequency 


Dose, 
Maximum 
in  24  hrs. 
Age  5  yrs. 


Asafetida,     Milk     of,    by 
rectum  only 

Aspidium  Oleoresin 

Aspirin 

Atropin 

Basham's  Mixture 

Belladonna  Tinct 

Beta-naphthol    

Benzoic  Acid    

Bismuth  Subcarbonate  .  . 

Bismuth  Subgallate 

(Dermatol) 

Bismuth  Subnitrate 

Bismuth  Salicylate 

Brandy  (Cognac)    

Bromide,  Ammonium  ] 

Bromide,  Potassium 

Bromide,  Sodium 

Bromide,  Strontium 

Brown    Mixture  (see  Lico- 
rice Comp.  Mixt.). 

Caffein  Citrate 

Calcium  Chlorid      

Calcium  Sulphid     

Calomel   


dr.  1 


gr.  1 


Camphor,  Pulverized 

Camphor  Spts.  10  per  cent. 
Cascara  Sagrada,  Ext  . .  .  . 
Cascara  Sagrada,  Fluid  Ext. 

Castor  Oil    

Cerium  Oxalate      

Chalk,  Prepared 

Chalk  Compound  Mixt 

Chloral  Hydrate 

Chloroform  Spirits 

Cinchona  (see  Quinin). 

Codein    

Cod-hver  Oil 

Creosote  

Creosote  Carbonate 

Digitalis,  Tinct .  .  . 

Digitalis,  Infusion    

Digitalin    

Dover's     Powders     (see 

Opium      Powders     of 

Ipecac). 

Dionin    

Ergot,  Fluid  Extract 

Ether,  Compound  Spts. 

(Hoffman's  Anodyne) .  .  . 
Ether,  Nitrous  Spts.  of 

(Sweet  Spirits  of  Niter) .  . 


gtt.  i 
gr.  \ 
gr.  1. 
gr.  5 


gr.  2-3 
gr.  5-10 
gr.  i-1 
gtt.  5-10 

gr.  1-3 


gr.  J-i 
gr.  i 
gr.  ^V 
gr.  A-i 

gr.  I'o 


dr.  1 


gr.  2 
dr.  1 
gr.  i 
gtt.  1-2 

gr.  A 
dr.  i 


gtt.  i 
gtt.  10 
gr.  Tih 


gr.  A 
gtt.  2-3 

gtt.  2 

gtt.  2 


dr.  1-2 
n^  10 
gr.  1-2 
gr-  ^h 
dr.  i 
gtt.  1 
gr.  i 
gr.  2 
gr.  10-15 


dr.  1-2 

TTl30 

gr.  3-5 
gr.  ih 
dr.  1 
gtt.  2-5 
gr.  1 
gr.  3-5 
gr.  15-30 


gr.  5-10        gr.  5-10 
gr.  10-15  [  gr.  10-30 
gr.  1-2  gr.  2-3 

gtt.  10-20    gtt.  20-30 


gr.  3-5 


gr.  i-h 
gr.  1 
gr.  A 
gr.  i-1 

gr.  i 
gtt.  5 
gr.  i 
gtt.  5 
dr.  1-2 
gr.  1-2 
gr.  3 
dr.  1 
gr.  1-2 
gtt.  2-3 

gr.  A 
dr.  i 
gtt.  1-2 
gtt.  1-2 
gtt.  1-2 
dr.  i 
gr-  tU 


gr.  ii^ 
gtt.  5 

gtt.  5 

gtt.  5 


gr.  5-8 


gr.  i 
gr.  2 

gr.  tV 
gr.  i-2 

gr.  i 
gtt.  5-10 
gr.  1-2 
gtt.  5-10 
dr.  1-4 
gr.  2-3 
gr.  5-8 
dr.  1-2 
gr.  2-3 
gtt.  5-10 

gr.  tV 
dr.  1-2 
gtt.  2-3 
gtt.  2-3 
gtt.  2-3 
dr.  1-3 
gr.  rh 


,gr.  tV 
gtt.  10-15 

gtt.  10 

gtt.  10 


pro  doso 

once 
q.  4  hrs. 
q.  4  hrs. 
t.i.d. 
q.  4  hrs. 
t.i.d. 
q.  4  hrs. 
p.r.n. 

p.r.n. 
p.r.n. 
p.r.n. 
q.  3  hrs. 

q.  4  hrs. 


q.  4  hrs. 

t.i.d. 

t.i.d. 
in  divided 

doses 
q.2  to  4  hrs. 

t.i.d. 

t.i.d. 

t.i.d. 

pro  doso 

t.i.d. 

q.  4  hrs. 

q.  3  hrs. 

q.  4  hrs. 

q.  4  hrs. 

q.4  hrs. 
t.i.d. 
t.i.d. 
t.i.d. 
q.  4  hrs. 
t.i.d. 
p.r.n. 


t.i.d. 
t.i.d. 

p.r.n. 

q.  1-2  hrs. 


dr.  2 
TTl^  10-30 
gr.  15-20 

gr.  ^V 
oz.  i 
r,i  5-10 
gr.  3 
gr.  5-10 
dr.  2-3 

dr.  2i 
oz.  i 
gr.  5-15 
dr.  1-oz.  i 

gr.  25-40 


gr.  2 
gr.  4-6 
gr.  T(T-i 
gr.  i-2 

gr.  ^-1 
ni  10-30 
gr.  2-5 
dr.  i 
oz.  i 
gr.  5-10 
gr.  20-30 
oz.  1 
gr.  5-10 
dr.  i 

gr.  i-f 
oz.  i-1 
gtt.  5-10 
gtt.  5-10 
gtt.  5-15 
dr.  3-oz.  1 
gr.  A 


gr.  i 
dr.  i 

dr.  i 

dr.  U 


GENERA^L  THERAPEUTICS. 
TABLE  OF  AVERAGE  DOSAGE.— Continued. 


63 


Drug 


Dose, 

Age 

6  mos. 


Dose, 

Age 

2  yrs. 


Dose, 

Age 

3  to  5  yrs. 


Dose, 
Frequency 


Dose, 
Maximum 
in  24  hrs. 
Age  5  yrs. 


Ferric  Prep,  (see  Iron). 
Fluoroform    (2.8    per  cent. 

sol.)     gtt.  1 

Fowler's   Sol.    (.see  Arsenic 

Liq.  Potass.).  , 

Glauber's  Salts 

Glonoin  (Nitroglycerin).   ..    gr.  ji^j 

Glonoin  (Spts.  of) gtt.  \ 

Guaiacol  Carbonate   gr.  i 

Heroin  Hydrochloric! gr.  yo^ 

Hexamethylenamin     (Uro- 

tropin)   gr.  i 

Hoffmann's   Anodyne    (see 

Ether  Spts.  Comp.). 
Hydrochloric    Acid,   Dilute    gtt.  ^ 

Hyoscyamus  Tinct gtt.  | 

Hydrargyrum  (see  Mercury), 
lodid,  Sodium,  and  Potas- 
sium       gr.  1 

j 
Iron .  ' 

Iron,  Oxid  Saccharated .  .  .    gr.  1 

Ferric  Chlorid,  Tine rr^  J 

Liq.  Ferri  et  Ammonium! 
Acetatis  (see  Basham'sl 
Mixt.).  I 

Soluble  Citrate  of  Iron 

(Ferri  et  Ammonii  Citras)    gr,  { 
Syrup  of  lodid  of  Iron : 


Pyrophosphate    of    Iron, 

(Soluble)  Elixir  of 

Reduced  Iron 

Liq.  Ferri  Peptonati  (N.F.) .     tt]^  5 
Ipecac,  Wine  of  (Emesis)  .  . .  gtt.  5 

Ipecac,  Syrup  of  (Expector-j 

ant)     gtt.  2 

Jalap,  Powdered gr.  i 

Licorice    Compound    Mixt. 

(Brown  Mixture) gtt.  15 

Liquorice  Compound  Pow- 
der      gr.  10 

Magma    Magnesia    (N.   F.) 

Milk  of  Mag ,   ni^  10 

Magnesium  Citrate  ■ 

(Liq.  Magnesia  Citrate 
Eflfervescent)     oz.  ^ 

Magnesium  Sulphate gr.  15 

Male  Fern,  Oleoresin  (see 
Aspidium). 

Mercury  Bichlorid gr.  ^^g 


gtt.  2 


gr.  30 

gr-  ^U 

gtt.  i 
gr.  1 
gr.  55 

gr.  1 


gtt.  2 
gtt.  2 


gr.  2 


gr.  2 
nil 


gr.  1 
gtt.  5 


"l  5 
gr.  i 
n\  10 
dr.  i 


gtt.  3 
gr.  2 


gtt.  6 


dr.  1 
gr.  jh 

gtt.   1 

gr.  5 
gr.  ?V 

gr,  2-5 


gtt.  5 
gtt.  3 


gr.  3 


gr.  5 
ni3 


gr.  3 
gtt.  5-10 


ni.15 
gr.  1 
rri  30 
dr.  i-1 


gtt.  5 
gr.  3 


q.  2  hrs. 


gtt.  48 


pro  doso    i  dr.  1-3 
q.  2-4  hrs.    gr.  i^ris 

q.  2-4  hrs.:  gtt.  4-8 
q.  4  hrs.       gr.  20 
q.  4  hrs.     i  gr.  j\^ 

t.i.d.  gr.  5-15 


t.i.d. 
t.i.d. 


t.i.d. 


t.i.d. 
t.i.d. 


t.i.d, 
t,i.d. 


t.i.d. 
t.i.d. 
t.i.d. 
q.  i  hrs. 
to  effect 

q   4  hrs. 


once 
gtt.  20-30    gtt.  30-40    q.  3  hrs. 


gr.  20 
dr.  i 


oz.  2 

gr.  30 


gr.  T*^ 


gr.  40-dr.l 
dr.  1 


oz.  4 

gr.  60 


gr.  jV 


bed  time 
t.i.d. 


in  A.  M. 
in  A.  M. 


t.i.d. 


gtt.  15 
gtt.  10 


gr.  5-10 


gr.  3-15 
nilG 


gr.  3-10 

gtt.  15- 

dr.  i 

itl  45 
gr.  3 

dr.  H 
dr,  3 


dr.  i 
gr.  3 

dr.  2-oz,  } 

dr.  J-1 

dr.  3 


oz.  6 
dr.  1 


gr.  15 


64 


DISEASES  OF  CHILDREN. 
TABLE  OF  AVERAGE  DOSAGE.— Continued. 


Drug 


Dose, 

Age 

6  mos. 


Dose, 

Age 

2  yrs. 


Dose, 

Age 

3  to  5  yrs. 


Dose, 
Frequency 


Dose, 
Maximum 
in  24  hrs. 
Age  5  yrs. 


Mercury       Mild       Chlorid' 

(Calomel) gr.  ^-i 

Mercury  Biniodid       '  gr.  yi^ 

Mercury  with  Chalk  (Gray 

Powder)   gr.  i 

Morphin  Sulphate 

Niter,  Sweet  Spirits  of  (see 
Ether  Spts.  Nitrous).        I 

Nitroglycerin  (see  Glonoin) ' 

Nux  Vomica  Tinct gtt.  1 

Novaspirin    gr.  1 

Opium  Tinct.  (Laudanum) 

Opium,  Camphorated  Tinct. 

Opium,  Power  of  Ipecac  and 
(Dover's  Powder) 

Peppermint    Water    (Aqua 
Mentha  Piperita) 

Pepsin  Powdered    

Pepsin  Essence  of  (N.  F.) . . 

Phenacetin      (Acetpheneti- 
din) 

Phosphorus 

Syr.  Calcii  Lactophos.    .  . 

Phosphoric  Acid  Dil 

Syr.  Hypophosphites  ... 

Potassium  Acetate , 

Potassium  Bitartrate 

Potassium   Bromid    

Potassium  Citrate    

Potassium  Chlorate    

Potassium     lodid    (Expec- 
torant)    

Potassium   lodid   (as  Anti- 
syphilitic)     

Quinin,    Sulphate   and    Bi- 
sulphate  

Rhubarb  Powdered    

Rhubarb  Syrup  Arom 

Rhubarb  and  Soda  Mixture 

Rhubarb    and     Anisated 
Magnesia  Pulv.  (N.  F.) .  . 

Salicin 

Sodium  Salicylate    

Methyl  Salicylate 

Aspirin \  gr.  1 

Oil  of  Wintergreen     gtt.  1 

Salol  . gr.  i 

Santonin    i 

Serum  Antidiphtheritic  (see' 
Antitoxin). 

Serum  .\ntimeningitic   ....     15  c.c. 

Sodium  Bpnzoate ,  gr.  1 


gtt.  3-5 
gr.  i-\ 

dr.  i 
gr.  1 
gtt.  20 

gr-  i 

gtt.  10 
gtt.  1-2 
gtt.  15 
gr.  1 
dr.  i 
gr.  1-3 
gr.  1 
gr.  i 

gr.  i 

gr.  1 

gr.  h 
gr.  1 
gtt.  15 

gr.  3 


gr.  i-1 

gr.  5V 

gr.  i 
gr.  5^ 


gtt.  2 
gr.  1-2 
gtt.  1-2 
gtt.  15 

gr.  f 

dr.  2 
gr.  2 
gtt.  30 

gr.  1 

gtt.  30 
gtt.  5 
gtt.  30 
gr.  3 
dr.  2 
gr.  3-5 
gr.  2 
gr.  2 

gr.  h 
gr.  2 

gr.  1-2 
gr.  3 
dr.  1-2 
dr.  i-1 

gr.  5-10 
gr.  1-2 
gr.  2 
gtt.  3 
gr.  1-2 
gtt.  3 
gr.  1-2 
gr.  i 


15  c.c. 
gr.  2 


gr.  i-2 

gr.  ^T 

gr.  i-1 
gr.  ^3 


gtt.  3-6 
gr.  3-5 
gtt.  2-3 
gtt.  20 


dr.  4 
gr.  3 
dr.  1 

gr.  2 

dr.  1 
gtt.  10 
dr.  i-1 
gr.  5 
dr.  4 
gr.  5-8 
gr.  5 
gr.  3 

gr.  1 

gr.  3 

gr.  2-3 
gr.  5 
dr.  1-2 
dr.  1-2 

gr.  10-20 
gr.  2-3 
gr.  3-5 
gtt   5 
gr.  3-5 
gtt.  5 
gr.  2-3 
gr.  i 

30  c.c, 
gr.  3 


in  divided    gr.  ^-2 
doses 
t.i.d.  gr.  I 


t.i.d. 
p.r.n. 


t.i.d. 
q.  4  hrs. 
p.r.n. 
q.  4  hrs. 


gr.  1-2  p.r.n. 


t.i.d. 
t.i.d. 
t.i.d. 


gr.  3 
gr.  iV 


gtt.  5-15 
gr.  15-20 
gtt.  10 
dr.  1-2 

gr.  1-5 

oz.  1-li 
gr.  5-10 
dr.  3 


q.  4  hrs.        gr.  4- 


t.i.d. 
t.i.d. 
t.i.d. 
t.i.d. 
once 
q.  4  hrs. 
q.  4  hrs. 
t.i.d. 


dr. 
dr. 
dr. 

gr. 
oz. 

gr. 
gr. 
gr. 


3 

i 
3 
15 

i 

25-40 
15-30 
10 


q.  2-4  hrs.    gr.  10 
t.i.d.  gr.  10 


q.  4  hrs. 
t.i.d. 
t.i.d. 
t.i.d. 

b.i.d. 
q.  3  hrs. 


gr.  5-15 
gr.  15 
oz.  i 
oz.  I 

gr.  40 
gr.  24 
dr.  i 
ni  20-30 
gr.  15-20 
gtt.  30 
gr.  10 
gr.  1-2 


daily  for  4      pro  doso 
I     days 
q.  4  hrs.        gr.  10-15 


q. 

3  hrs. 

q. 

2-3  hrs. 

q. 

4  hrs. 

q- 

2-3  hrs. 

t. 

.d. 

q- 

4  hrs. 

GENERAL  THERAPEUTICS. 
TABLE  OF  AVERAGE  BOS  AGE. —Continued. 


65 


Drug 


Dose, 

Age 

6  mos. 


Dose, 

Age 

2  yrs. 


Dose, 

Age 

3  to  5  yrs. 


Sodium  Bicarbonate 
Sodium  Bromid .... 

Sodium  lodid 

Sodium  Phosphate  . 
Sodium  Sulphate    .  . 
Spartein  Sulphate    . 
Strophanthus   Tinct. 
Strychnin  Sulphate 

Tanalbin 

Tannigen 

Tartar  Emetic     

Terpin  Hydrate 
Thyroid  Ext.  Desic. . 

Thymol    

Urotropin    

Veronal 

Whisky 


gr.  2 
gr.  1-3 
gr.  1 
gr.  15 


gtt.  1 

gr-  Tk 
gr.  1 
gr.  1 
gr.  ^U 


gr.  i-1 
gr.  i 
gtt.  10 


gr.  30 
gr.  30 

gr.  ?V-Ttf 
gtt.  2 

cm        '     _.     1 
gr.  ^TTB    To?? 

gr.  3 
gr.  3 
gr.  Ti^ 
gr.  i 
gr.  1-2 
gr.  1-2 
gr.  1 
gr.  1 
gtt.  10-20 


gr.  5-10 
gr.  5-8 
gr.  3 
gr.  60 
gr.  60 

gr-To-i 
gtt.  3 

gr.  tU 
gr.  5 
gr.  5 
gr.  rk 
gr.  i 
gr.  3 
gr.  2-5 
gr.  2-5 
gr.  1-2 
gtt.  30-40 


Dose, 
Frequency 


p.r.n. 
q.  4  hrs. 
t.i.d. 
pro  doso 
pro  doso 
q.  3  hrs. 

4  hrs. 

4  hrs. 

2  hrs. 

2  hrs. 

4  hrs. 

3-4  hrs. 


t.i.d. 
t.i.d. 
t.i.d. 
once 
q.  4  hrs. 
or  oftener 


Dose, 
Maximum 
in  24  hrs. 
Age  5  yrs. 


gr.  20-30 
gr.  25-40 
gr.  5-10 
dr.  1 
dr.  1-3 
gr.  i 
gtt.  12 

gr-  55 
dr.  1 
dr.  1 

gr.  A 
gr.  3 
gr.  9 
gr.  15 
gr.  5-15 
gr.  2 
oz.  J 


Introductory  Remarks. 

The  treatment  of  diseases  in  children  requires  a  thorough  knowl- 
edge of  all  measures,  besides  drugs,  that  may  be  used  for  alleviation 
or  cure.  If  the  medical  attendant  places  sufficient  dependence  upon 
such  measures  as  hydrotherapy,  fresh  air,  and  diet  he  will  be  inclined 
to  order  fewer  drugs  or  only  such  as  are  still  indicated.  Familiarity 
with  the  details  of  the  general  therapeutics  of  childhood  will  make 
him  resourceful  and  capable  of  adapting  his  treatment  to  the  particular 
surroundings  and  needs  of  the  child. 

The  physician  should  take  into  consideration  the  general  develop- 
mental condition  of  the  child,  its  usual  habits  and  the  intelligence 
of  those  who  will  carry  out  his  orders.  Orders  should  always  be  spe- 
cific, and  are  preferably  written  out  in  detail,  as  a  mother's  anxiety 
for  her  sick  child  may  lead  to  misunderstandings  which  may  prove 
serious. 

While  many  of  the  diseases  are  self-limited,  and  recoveries  are 
generally  speedy  because  of  the  recuperative  powers  in  early  life, 
still  the  practitioner  should  always  alleviate  distress  and  hasten 
complete  recovery  by  the  proper  use  of  drugs  and  other  medical 
measures. 

Prescriptions  should  be  simple,  containing  only  one  or  two  in- 
5 


66  DISEASES  OF  CHILDREN. 

gredients,  and  made  as  palatable  as  possible  without  endangering  the 
child's  digestion.  Glycerin  or  saccharin  well  serve  this  purpose 
and  are  to  be  preferred  to  the  syrups  or  sweet  elixirs  which  so  readily 
cause  fermentation.  Medication  and  other  measures  for  relief  should 
be  so  arranged  that  th^  child  will  not  be  continually  disturbed;  for 
rest  is  an  important  adjunct  in  all  cases. 

In  the  practice  of  pediatrics  preventive  treatment  should  be 
considered  first,  last,  and  all  the  time,  for  it  is  only  thus,  through 
the  saving  of  lives  and  the  rearing  of  healthy  children  who  can  later 
become  healthy  parents,  that  infant  mortality  can  really  be  reduced. 

Psychotherapy. 

The  influence  that  can  be  exerted  for  good  or  evil,  over  the  recep- 
cive  mind  of  a  child  has  been  well  emphasized  in  recent  years  by  psy- 
thologists  and  physicians.  Often  a  good  part  of  a  physician's  success 
in  handling  little  patients  is  due  to  his  knowledge  and  interest  in  their 
mental  processes.  He  learns  to  take  advantage  of  their  susceptibility 
to  conviction,  to  suggestion,  or  of  their  pride,  and  control  is  thus  easily 
acquired.  The  harmful  influence  of  certain  members  of  the  family 
may  prevent  good  results,  especially  in  neurotic  diseases,  until  the  child 
is  removed  to  different  surroundings.  A  stranger  often  has  better 
control  over  the  sick  child  than  its  own  mother.  Time  spent  in  study- 
ing the  mental  attributes  of  a  seemingly  incorrigible  patient  is  well 
spent,  for  almost  without  exception  the  maturer  mind  conquers  by  per- 
sistence tempered  with  kind  indifference. 

In  older  children  hysterical  manifestations  can  be  controlled  by 
the  forceful  attendant  and  their  repetition  prevented  by  a  radical 
change  in  environment  and  daily  routine.  Such  conditions  as  enuresis 
we  have  often  been  able  to  cure  by  psychic  influences  depending 
mainly  upon  the  child's  pride.  Another  factor  often  lost  sight  of  in 
this  connection  is  the  influence  of  associates.  Through  a  proper 
selection  of  playmates  in  age  and  temperament,  much  may  be  done, 
from  a  psychic  standpoint. 

Aero  therapy. 

It  is  a  deplorable  fact  that  there  is  any  need  of  emphazing  the 
use  of  fresh  air  in  the  treatment  of  disease.  The  laity,  however,  have 
been  so  imbued  for  years  with  the  idea  that  colds  are  the  result  of  cold 
air,  and  that  sickness  in  the  house  demands  warm  rooms  that  the 
practitioner,  in  spite  of  his  better  judgment,  often  acquiesces  in  these 
notions.     Among  the  more  intelligent  of  our  population  the  need  of 


GENERAL  THERAPEUTICS. 


67 


Fig.    17. — Aerotherapy   in    the    tenements — improvised    portable 
bed  from  bath-tub. 


68  DISEASES  OF  CHILDREN. 

an  outdoor  life  is  beginning  to  be  appreciated,  and  it  only  demands  that 
orders  for  sufficient  fresh  air  be  given  with  a  spirit  of  conviction  that 
the  method  is  a  right  and  just  one,  to  gain  the  cooperation  of  the 
parents.  The  harmful  influence  of  impure  air  or  a  paucity  of  fresh 
air  is  no  better  illustrated  than  by  comparing  the  poor  results  formerly 
obtained  in  institutions  and  hospitals  for  children,  even  when  skillful 
nursing  was  at  hand,  to  the  good  results  obtained  with  abundance  of 
fresh  air. 

Aerotherapy,  or  an  abundance  of  pure  fresh  air,  should  be  ar- 
ranged for  in  every  sick-room  as  well  as  in  the  nurseries  of  healthy  chil- 
dren. In  respiratory  diseases  accompanied  with  fever  the  good 
effects  of  cool  fresh  air  are  particularly  noticeable. 

In  convalescence  a  change  to  the  country  or  seaside,  where  ozone 
is  abundant,  will  do  more  than  a  course  of  iron  tonics  or  artificial  stimu- 
lants. The  summer  diarrheas  are  often  promptly  alleviated  by  a  so- 
journ in  a  cool  and  dry  atmosphere. 

Hydrotheraphy. 

The  use  of  water  is  safer  and  often  more  effective  than  the  use 
of  antipyretics  in  reducing  temperature.  It  also  has  a  tonic  effect 
instead  of  the  depressing  effect  of  antipyretic  drugs.  A  warm  bath 
given  to  a  child  conserves  the  body  heat,  is  sedative  in  its  action,  and 
increases  the  perspiration.  On  the  other  hand,  cold  baths  decrease 
the  body  heat  and  leave  a  stimulating  and  eliminative  action. 

Sponge  Baths. — Cool  sponge  baths  with  or  without  alcohol  are 
effectual  and  usually  agreeable  to  children  when  their  temperature  is 
high.  Cold  baths  or  cold  packs  are  rarely  necessary  and  may  be  pro- 
ductive of  considerable  shock.  Equal  parts  of  alcohol  and  water  at 
90°  F.  are  applied  to  the  child  lying  in  a  woolen  blanket;  gentle  friction 
causes  air  evaporation  and  reduction  of  temperature.  While  the  bath 
is  in  progress  ice  cold  cloths  may  be  placed  on  the  forehead  and  head  of 
the  child. 

Sheet  or  Bed  Baths. — Rubber  sheeting  is  spread  on  the  bed  and  a 
soft  sheet  or  blanket  is  wrung  out  of  water  at  90°  to  100°  F.  The 
patient  is  wrapped  in  this  and  cold  applications  at  60°  F.  placed  to  the 
head.  In  older  children  water  at  a  lower  temperature  70°  or  80°  F. 
may  be  sprinkled  over  the  sheet  to  effect  a  further  reduction  of  body 
heat.  The  patient  should  remain  in  such  a  bath  for  about  twenty 
minutes  and  it  may  be  repeated  several  times  during  the  day  if  the 
necessity  arises. 

Ice  Cap. — For  persistent  high  temperature  with  delirium  an  ice 
cap  may  be  placed  at  the  nape  of  the  neck  or  on  top  of  the  occiput. 


GENERAL  THERAPEUTICS.  69 

The  thin  rubber  ice  bladders  are  half  filled  with  small  pieces  of  cracked 
ice  and  all  air  is  expelled.  They  should  be  used  only  intermittently, 
and  a  trained  attendant  should  be  present  as  all  cases  do  not  respond 
well  to  its  application. 

Ice  Poultice. — Small  pieces  of  cracked  ice  are  mixed  with  an 
equal  jDortion  of  bran  or  sawdust  and  wrapped  in  oil  silk  or  rubber 
sheeting  in  such  a  way  as  to  prevent  leaking.  This  may  be  used  as  the 
ice  cap  above,  but  has  the  advantage  that  it  may  be  improvised  at 
home. 

Compresses  — Compresses  wrung  out  of  water  varying  from 
80°  to  100°  F.  according  to  indications  may  be  applied  to  the  neck  in 
tonsilitis,  over  the  abdomen  for  enteralgia  and  about  the  chest  in  cases 
of  pneumonia.  When  used  on  the  chest  they  should  be  divided  into 
two  portions,  one  for  the  left  and  one  for  the  right,  so  that  they  may 
be  removed  with  as  little  disturbance  as  possible  to  the  patient. 
They  may  also  be  applied  to  the  exposed  part  of  the  chest  in  one  piece 
and  tucked  around  as  far  as  possible  without  disturbing  the  child. 

Warm  and  hot  baths  are  agreeable,  soothing,  and  sedative.  The 
temperature  of  the  body  is  reduced  and  the  relaxation  which  follows 
promotes  sleep.  Diuresis  is  also  promoted.  A  warm  bath  is  given  at 
a  temperature  of  85°  to  98°  F.,  while  a  hot  bath  may  range  to  110°  F. 
The  warm  bath  is  suitable  for  the  reduction  of  temperature,  and  should 
last  from  five  to  fifteen  minutes.  Cool  applications  may  be  placed 
upon  the  head  if  the  pyrexia  is  particularly  high.  Hot  baths  should 
be  given  to  asthenic  infants  when  the  temperature  is  high  or  sub- 
normal. The  addition  of  mustard  is  useful,  especially  if  there  are  evi- 
dences of  shock  or  collapse.  The  baths  should  be  short,  not  exceeding 
over  five  minutes  in  duration.  The  patient  should  be  wrapped  in 
warmed  woolen  blankets  and  allowed  to  rest,  unless  free  perspiration 
is  indicated  as  in  nephritis,  when  hot  drinks  may  also  be  given. 

A  hot  pack  is  useful  in  nephritic  or  uremic  cases.  The  child  is 
wrapped  in  a  woolen  blanket  wrung  out  of  water  at  110°  F.  and  covered 
with  another  dry  one,  beneath  which  are  placed  numerous  hot-water 
bags.  Hot  drinks  are  offered.  The  pulse  should  be  watched  and  the 
child  removed  when  a  free  perspiration  is  induced. 

A  hot-air  bath  is  given  by  introducing  hot  air  from  a  croup  kettle 
under  the  blankets  of  the  bed  for  about  half  an  hour  or  until  free 
diaphoresis  is  obtained. 

Special  Baths. 

A  brine  bath  is  given  by  adding  a  half-pound  of  sea  salt  to  six 
gallons  of  water  at  a  temperature  of  105°  F.  and  gradually  reducing  to 


70 


DISEASES  OF  CHILDREN. 


90°  F.  Gentle  friction  should  be  kept  up  throughout  the  bath  which 
should  not  last  longer  than  fifteen  minutes.  It  is  indicated  as  a 
stimulating  bath  for  undernourished,  poorly  developed  children,  es- 
pecially those  with  scrofulous  tendencies. 

The  addition  of  bran,  starch  or  bicarbonate  of  soda  in  luke-warm 
water  will  serve  to  allay  the  irritation  of  certain  skin  diseases,  as  urti- 


FiG.  18. — Method  of  giving  hot  dry  pack. 


caria.  A  quarter  of  a  pound  of  soda  is  sufficient  for  a  six-gallon  b^th. 
When  a  bran  bath  is  given  half  a  pint  of  bran  in  a  cheesecloth  bag  is 
drawn  through  the  water.  For  the  starch  bath  a  quarter  of  a  pound, 
or  half  a  cup,  of  raw  starch  is  slowly  dissolved  in  the  water. 

A  soothing  bath  which  will  promote  sleep  in  nervous,  irritable 
children  is  made  In-  the  addition  of  fifteen  drops  of  pine-needle  oil  to 
the  water  at  110°  F.     No  friction  should  be  made. 

A  mustard  bath  is  prepared  by  immersing  an  ounce  of  mustard  in 
a  cheese  cloth  or  muslin  bag  in  the  water  usually  at  a  temperature  of 


GENERAL  THERAPEUTICS.  71 

105°  F.     Cold  compresses  are  applied  to  the  head,  and  the  body  is 
gently  rubbed. 

Carbonic  acid  baths  (artificial  Nauheim  baths)  may  be  prepared 
by  the  addition  of  chemicals  or  specially  prepared  Triton  salts  to  the 
water,  but  the  evolution  of  the  gas  is  somewhat  uncertain  and  irregular. 
The  gas  may  be  generated  by  the  action  of  bicarbonate  of  soda  and 
hydrochloric  acid  in  a  porcelain-lined  tub.  The  acid  being  diffused 
through  the  water  after  the  soda  has  been  dissolved.  Another 
method  has  recently  been  placed  on  the  market  which  is  dependent 
upon  the  use  of  a  specially  constructeil  mat  through  which  the  gas  is 
allowed  to  flow  from  a  cylinder  of  the  compressed 
gas.  The  flow  of  gas  is  greater,  it  is  more  everJv 
distributed  through  the  bath  and  it  can  be  regulated. 
It  is  certainly  preferable  to  the  older  methods  for 
home  use  (Fig.  19).     The  bath  is  given  at  90°  to  95= 


19. — Caroonic  acid  gas  bath,  with  seat,  tank,  and  manometer  for  home  use. 

ftOBERT  D.  &  LORA  6.  £M£fty. 

F.  for  five  minutes  and  is  followed  by  gentle  friction  and  res*  in  bed 
for  several  hours.  These  baths  must  be  given  at  least  three  times  a 
week  for  several  months  to  produce  permanently  good  effects.  The 
baths  are  indicated  in  the  convalescent  stages  of  myocardial  diseases. 

The  Nasopharyngeal  Toilet. 

The  nasopharyngeal  toilet,  as  advocated  by  Caille,  is  a  valuable 
prophylactic  measure  in  diseases  affecting  or  emanating  from  the  res- 
piratory tract,  and  is  an  effective  adjunct  in  promoting  a  healthy 
condition  of  the  nasopharyngeal  mucous  membrane  in  many  febrile 
diseases. 

Method. — The  method  consists  in  slowly  pouring  into  each  nostril, 
by  means  of  an  ordinary  teaspoon,  a  drachm  of  normal  salt  solution 
while  the  child  lies  wath  his  head  tilted  back  over  a  pillow  and  his 
mouth  open.     If  gentleness  is  combined  with  tact  when  the  measure 


72  DISEASES  OF  CHILDREN. 

is  first  attempted,  the  child  soon  learns  that  the  method  is  not  painful 
nor  disagreeable.  It  can  be  used  to  advantage  in  such  infectious  dis- 
eases as  diphtheria  and  scarlatina,  and  before  and  after  operations  upon 
the  nose  and  throat,  as  in  adenectomy  and  tonsillotomy  and  retro- 
pharyngeal abscess. 

Lavage. 

(Stomach  Washing) 

This  is  a  useful  practice,  but  one  which  is  often  much  abused. 
It  is  indicated  as  an  initial  procedure  for  persistent  vomiting,  especially 
in  summer  diarrhea,  in  cases  of  chronic  gastrointestinal  indigestion, 
acute  gastritis,  poisoning,  in  persistent  vomiting,  and  preceding  certain 
operative  procedures  as  intestinal  obstruction.  Repeated  stomach 
washing  is  to  be  deprecated.  If  the  symptoms  persist  it  is  usually  an 
indication  that  the  dietary  regulation  is  faulty. 

The  apparatus  used  is  made  with  a  soft-rubber  catheter.  No.  12 
American,  attached  by  means  of  a  piece  of  glass  tubing  to  another  length 
of  rubber  tubing  at  the  end  of  which  is  placed  a  small  funnel.  The 
catheter  is  introduced  into  the  esophagus  without  any  difficulty  and 
with  little  discomfort  to  the  infant.  A  warmed  fluid  which  may  be 
either  a  normal  saline  solution,  or  contain  bicarbonate  of  soda  (a 
dram  to  the  pint)  or  boric  acid  2  per  cent,  is  used  in  amounts  depend- 
ing upon  the  age  and  development  of  the  child  (see  Chap.  V).  When 
the  stomach  is  full  this  will  be  noted  in  the  funnel,  which  is  then 
depressed  and  the  contents  siphoned  off.  This  process  is  repeated 
until  the  return  flow  is  clear.  The  preferable  method  is  to  hold  the 
child  upright  in  the  nurse's  lap,  the  head  being  slightly  inclined  for- 
ward; if  for  any  reason  this  is  contraindicated  the  infant  may  be 
placed  on  its  side,  but  this  position  requires  more  dexterity  than  the 
upright. 

Enteroclysis. 

Enterocylsis  is  a  measure  which  can  readily  be  used  in  infants  and 
children.  No  special  apparatus  is  required  as  in  venous  infusions  or 
hypodermoclysis.  In  the  latter,  surgical  cleanliness  must  be  strictly 
observed,  and  it  is  difficult  to  carry  out  the  technic,  without  trained 
assistants,  outside  of  a  hospital.  Flushing  the  colon  not  only  clears 
out  the  lower  intestinal  tract  of  deleterious  material,  but  it  stimulates 
renal  secretion,  thus  promoting  the  excretion  of  toxic  products.  If 
there  is  high  temperature  this  will  be  reduced  and  thirst  assuaged. 
The  absorption  of  the  fluid  increases  the  blood  pressure,  and  by  elimi- 


GENERAL  THERAPEUTICS.  73 

nating  poisonous  products  indirectly  assists  in  renewing  the  condition 
of  the  blood  itself. 

Method. — A  soft-rubber  rectal  tube  is  attached  to  the  end  of  a 
fountain  bag  into  which  has  been  poured  a  saline  solution  made  by 
dissolving  two  teaspoonfuls  of  salt  to  two  quarts  of  water  at  110°  F. 
The  bag  should  be  hung  about  three  feet  above  the  patient  and  the 
water  allowed  to  flow  slowly  into  the  gut.     If  the  intestine  is  irritable 


Fig.  2U. — Method  of  performing  hypodermoclysis. 

the  pressure  may  be  lowered  so  that  the  water  will  flow  very  slowly 
after  the  bowel  has  been  emptied.  Fluids  will  not  penetrate  beyond 
the  ileocecal  valve,  but  the  entire  intestinal  tract  will  be  stimulated  to 
greater  activity  by  the  process. 

In  place  of  the  saline  solution  it  is  often  of  advantage  to  use  a 
bland  soothing  preparation,  such  as  starch  water,  or,  on  the  contrary, 
soap  suds  may  be  necessary  if  the  intestine  is  inactive. 

The  indications  for  flushing  or  irrigation  of  the  bowel  are  the 
removal  of  the  putrescent  material,  as  in  enteritis  and  cholera  infan- 
tum, and   to   assist  elimination  in   the  infectious   diseases,  such  as 


74 


DISEASES  OF  CHILDREN. 


typhoid  and  scarlet  fever.  It  is  also  of  distinct  value  in  septic  condi- 
tions and  nephritis.  In  conjunction  with  baths  it  may  also  be  used 
to  reduce  high  temperatures,  thus  counteracting  the  harmful  effects 
produced  by  the  loss  of  fluids  in  the  tissues.  Once  a  day  is  usually 
sufficient.  The  mucous  membrane  is  rendered  irritable  by  too  frequent 
irrigations. 


Fig.  21. — Enteroclysis:  position  of  the  patient  for  bowel  irrigation. 


Gavage. 

Gavage,  or  forced  feeding  by  the  stomach-tube,  is  accomplished 
with  the  same  kind  of  apparatus  as  that  used  for  enteroclysis,  that  is, 
a  No.  12  American,  soft-rubber  catheter,  a  piece  of  tubing  and  an  eight- 
ounce  funnel,  preferably  of  glass.  The  upright  or  the  prone  position, 
with  the  child  lying  on  its  back,  may  be  selected.  With  infants  no 
mouth-gag  is  required.  In  older  children  a  mouth-gag,  well  protected 
by  pieces  of  rubber  to  prevent  laceration  of  the  gums,  will  be  necessary. 
Before  introducing  the  food  for  the  first  time  it  is  better  to  do  a  prelimi- 
nary stomach  washing.  The  food  is  allowed  to  flow  slowly  into  the 
stomach     and   when   the  desired  amount   has   been   introduced   the 


GENERAL  THERAPEUTICS.  75 

catheter  should  be  quickly  withdrawn,  the  tube  first  being  firmly 
pinched  to  prevent  regurgitation  and  the  entrance  of  any  of  its 
contents  into  the  larynx.  The  infant  should  then  be  placed  in  bed 
and  not  disturbed,  as  in  highly  irritable  conditions  the  food  might 
be  regurgitated. 


Fig.  22. — Position  and  apparatus  for  gavage. 

The  indications  for  gavage  are  the  feeding  of  premature  or  asthenic 
infants  who  are  unable  to  otherwise  take  their  food,  cases  of  habitual 
or  obstinate  vomiting  in  which  the  infants,  as  shown  by  Kerley,  may 
vomit  the  food  when  swallowed,  but  retain  it  when  given  by  the  tube. 
Occasionally  following  intubation  or  operations  on  the  esophagus,  feed- 
ing by  gavage  is  necessary.  During  meningitis  or  conditions  in  which 
there  is  coma,  forced  feeding  may  be  indicated;  as  rectal  feeding, 
except  for  a  day  or  two,  is  of  little  value  in  early  life. 


76  DISEASES  OF  CHILDREN. 

The  food  used  may  be  breast  milk,  full  strength  or  diluted,  modi- 
fied or  peptonized  cow's  milk,  plain  or  dextrinized  gruels.  The 
amounts  should  be  somewhat  below  the  usual  requirements  and  the 
periods  of  feeding  lengthened.  Care  should  be  taken  that  the  food 
is  sufficiently  warmed  when  it  enters  the  stomach,  as  a  luke-warm 
temperature  is  apt  to  induce  vomiting. 

Rectal  Feeding — Nutrient  Enemata. 

Rectal  feeding  is  rarely  of  service  except  for  temporary  use, 
as  very  little  nutriment  is  absorbed.  It  may  be  possible  to  check 
body  waste  by  this  means,  but  we  have  never  seen  increase  in  weight, 
when  this  was  the  only  form  of  feeding.  It  is  indicated  in  cases  of 
cyclic  or  incessant  vomiting  or  where  there  is  an  inability  to  swallow, 
in  certain  operative  cases  and  when  the  food  is  not  tolerated  by  the 
stomach. 

Method. — The  rectum  should  be  cleansed  with  a  bland  enema,  as 
saline  solution,  and  an  interval  of  at  least  a  half-hour  should  be  allowed 
before  injecting  the  food  into  the  rectum.  The  child  is  placed  on 
his  back  or  left  side  with  the  thighs  well  elevated.  The  prepared 
food  is  allowed  to  flow  into  the  rectum  from  an  ordinary  fountain  bag 
to  the  end  of  which  has  been  attached  a  small-sized  colon  tube  or  large- 
sized  catheter.  If  the  anus  and  tube  are  well  anointed  with  vaseline 
the;  tube  may  be  advantageously  passed  well  up  into  the  colon.  If 
this  is  slowly  and  gently  done,  peristalsis  will  not  be  excited,  and  the 
contents  of  the  bag  held  just  high  enough  to  permit  a  flow  will  be 
more  apt  to  be  retained. 

Infants  will  retain  about  two  to  six  ounces,  young  children  four 
to  ten  ounces.  These  enemata  may  be  given  three  or  four  times  in 
the  twenty-four  hours.  Smaller  amounts  are  always  better  tolerated 
and  retained  than  larger  quantities.  When  the  rectal  tube  is  with- 
drawn the  buttocks  should  be  pressed  together,  the  child  still  retaining 
the  recumbent  posture.  The  fluids  that  may  be  used  are  peptonized 
or  pancreatinized  milk,  eggs,  albumin,  and  gruels,  or  a  combination  of 
these.  Occasionally  stimulants  or  other  drugs  may  be  added  to  the 
food. 

Vaccine  Therapy. 

Wright  has  demonstrated  in  blood  serum  certain  bodies  which  he 
calls  opsonins,  which  possess  the  property  of  so  affecting  bacteria  that 
they  may  be  ingested  and  destroyed  by  the  phagocytes. 

In  some  respects  opsonins  resemble  ferments;  they  may  be  dried 


GENERAL  THERAPEUTICS.  77 

and  still  retain  their  power  for  many  months;  they  resist  exposure 
to  a  temperature  "of  120°  C;  their  power  is  not  especially  diminished 
by  dilution  and  they  act  most  actively  in  an  alkaline  medium. 

Opsonins  are  probably  formed  in  muscle  and  subcutaneous  tissue, 
but  not  in  the  blood.  As  to  their  structure,  various  ideas  are  held, 
some  believing  that  they  are  identical  with  certain  other  immune 
bodies  as  amboceptors  and  complements;  other  authorities  believe 
that  they  are  not  identical  with  these  bodies,  but  resemble  toxins. 
Wright  is  of  the  opinion  that  they  are  in  a  class  by  themselves. 

But  little  is  known  regarding  the  fate  of  opsonins  in  the  organism. 
The  opsonic  index  is  the  ratio  of  the  opsonic  content  of  a  unit  volume 
of  the  patient's  blood  serum  to  that  in  a  unit  volume  of  a  normal  in- 
dividual. (For  method  and  technic  of  this  determination  the  reader  is 
referred  to  Wright's  original  paper.) 

The  Reaction  of  Immunization. — When  an  inoculation  of  bacterial 
vaccine  is  given  in  quantity  sufficient  to  produce  a  slight  constitutional 
reaction,  the  first  result  is  a  fall  in  the  antibacterial  power  of  the  blood. 
This  phase  is  designated  by  Wright  as  "the  ebb"  or  negative  phase. 
This  phase  is  succeeded  by  a  rise  in  the  antibacterial  power  of  the 
blood,  and  is  termed  "the  flow"  or  positive  phase.  After  a  varying 
interval  there  again  occurs. a  fall,  termed  ''the  backflow, "  to  a  point 
somewhere  above  the  starting-point.  This  higher  plane  is  known 
as  the  "sustained  high  tide  of  immunity." 

Such  a  sequence  occurs  after  a  correct  quantity  of  vaccine  has 
been  inoculated.  Too  great  an  amount  will  produce  untoward  consti- 
tutional symptoms  and  a  proportionately  greater  negative  phase 
results  which  may  be  prolonged,  and  possibly  no  positive  phase  will 
occur. 

By  properly  timing  the  inoculations  so  that  a  second  is  given 
when  the  positive  phase  is  well-established,  a  similar  sequence  is  pro- 
duced giving  a  reinforced  positive  phase  with  increased  antibacterial 
power  in  the  blood. 

Preparation  of  the  Vaccine. — To  obtain  the  best  results  by  inocu- 
lation, it  is  advisable  to  prepare  the  vaccine  from  the  organisms  caus- 
ing the  lesion  in  the  patient.  For  example,  if  the  patient  is  suffering 
from  furunculosis,  pus  from  one  of  the  pustules  is  used  for  inocula- 
tion of  the  culture  tubes. 

The  vaccine  treatment  of  disease  has  shown  its  best  results  in 
cases  of  furunculosis  and  in  gonorrheal  infections.  In  tuberculous 
disease,  the  results  of  vaccine  treatment  are  encouraging  except  in 
the  meningitic  form.  In  pneumococcic  infections  the  best  results  are 
obtained  in  cases  of  delayed  resolution.      Vaccines  in  typhoid  fever 


78 


DISEASES  OF  CHILDREN. 


Ik         /  ^^1 

■■bMMUSSliiiiten^ 


Fig.  23. — Exercises  for  developing  children  with  deformities:  (a)  narrow  fiat 
chest  in  a  mouth  breather;  (b)  showing  winged  scapulse  and  curvature;  (c)  and 
(d)  corrective  exercises. 


GENERAL  THERAPEUTICS. 


79 


moderate  the  severity  of  the  disease,  but  may  prolong  the  attack. 
Recorded  cases  of  successful  treatment  of  meningococcic  infections 
are  very  few. 

Breathing  and  Resistant  Exercises. 

While  special  physical  training  is  important  and  often  opportune 
in  the  cure  of  deformities  and  badly-developed  children,  a  greater 
proportion  of  all  children  need  some  systematic  training  in  the  act  of 
correct  breathing  and  instruction  as  to  correct  posture. 

The  schools  in  some  of  the  larger  cities  are  making  some  valuable 
efforts  along  these  lines,  through  physical  directors  who  have  made  a 


i: 

Fig.  24. — Exercise.s  useful  for  increasing  respiratory  capacity. 


study  of  life  during  the  developmental  stage.  At  this  time  good 
habits  are  easily  inculcated;  later,  in  adult  life,  they  are  brought  about 
only  with  difficulty  and  the  expenditure  of  valuable  time. 

If  breathing  as  an  art  is  taught  the  child,  it  will  develop  its  lung 
capacity  and  supply  the  proper  amount  of  oxygen  to  the  growing 
tissues.  Each  breath  should  be  taken  in  slowly  through  the  nostrils 
in  as  large  a  quantity  as  is  comfortable  without  effort;  gradually  this 
amount  is  increased  as  the  natural  elasticity  of  the  lungs  is  increased, 


80  DISEASES  OF  CHILDREN. 

and  in  a  short  time,  with  thought  and  practice,  diaphragmatic  breathing 
becomes  the  natural  breathing  of  the  child. 

In  the  Logi  method,  the  patient  lies  on  the  floor  upon  a  sheet, 
with  windows  wide  open  and  clothing  perfectly  free.  One  nostril  is 
closed  and  an  inhalation  taken  and  held  a  few  seconds  before  exhaling 
through  the  opposite  nostril,  and  this  is  repeated  several  times  with 
frequent  pauses  for  rest  and  diversion. 

The  next  step  is  the  development  of  intercostal  breathing;  later 
the  accessory  breathing  muscles  are  utilized,  and  finally  the  so-called 
complete  breathing  is  perfected.  The  best  results  are  obtained  when 
individual  instruction  is  given  by  a  competent  teacher. 

The  parents  may  later  act  as  monitors  and  encourage  the  chil- 
dren to  go  through  their  exercises  daily.  As  a  rule,  the  little  patients 
delight  in  this,  and  consider  it  a  pleasure  rather  than  a  task.  B}^  con- 
tinuing slow,  resistant  exercises  with  the  deep  diaphragmatic  breathing, 
placing  the  pupil  before  a  mirror  and  teaching  him  to  concentrate  his 
mind  upon  each  movement,  the  general  tone  of  the  body  can  be 
markedly  raised.  Twice  a  week  for  fifteen-minute  periods  usually 
suffices  in  the  beginning. 

The  aim  should  not  be  to  produce  great  muscular  development,  but 
simply  to  create  a  natural  demand  for  proper  food,  improve  the 
general  circulation,  and  bring  about  better  health. 

The  indications  for  these  exercises  are  many,  but  the  best  results 
are  obtained  in  children  who  are  shallow  mouth-breathers  as  a  result 
of  various  disorders  of  the  respiratory  tract  or  of  nutrition.  We  have 
had  excellent  results  with  this  method  following  adenoid  operations, 
in  rachitic  and  anemic  children  with  perverted  appetites.  Neurotic 
children  react  very  favorably. 


CHAPTER  X. 

SUGGESTIVE  SCHEME  FOR  DIAGNOSIS. 

To  confirm  the  suggestions  for  diagnosis  in  this  table  the  reader 
can  refer  to  the  section  that  treats  at  length  of  the  diseases  suggested. 

Head. 
Size. 

(a)  Small — Microcephalus,  idiocy. 

(6)   Large — Hydrocephalus,  rickets,  hypertrophia  cerebri. 
Shape. 

(a)  Square — Rickets.     (Prominent  frontal  eminences.) 

(b)  Asymmetrical — Rickets,    cretinism,    idiocy,    brain    tumors, 
atrophy  of  brain. 

(c)  Bulging  Forehead — Hydrocephalus. 

(d)  Prominent  Frontal  and  Parietal  Bones — Syphilis. 

(e)  Craniotabes — Syphilis,  rickets,  chondrodystrophy. 

(/)    Open  Sutures — Rickets,  hydrocephalus,  cretinism,  idiocy. 
Position. 

(a)  Retraction — Meningitis,  Pott's  disease. 

(6)  Lateral  Deviation— Wry  neck,  rheumatic  torticollis.  Pott's 
disease,  injury  to  neck  muscles  at  birth,  abscess.  (Peri- 
tonsilar,  postpharyngeal  or  of  cervical  glands.)  Middle 
ear  or  mastoid,  hematoma,  sternomastoid,  curvature, 
hysteria. 
Motion. 

(a)  Purposeless  Movements — Chorea,  tics. 

(b)  Rythmic — Nodding  spasm. 

(c)  Flaccidity — Anterior  poliomyelitis,  coma,  late  meningitis. 
Fontanel.     (Normally  open  till  eighteenth  month.) 

(a)  Bulging   (during    cry    normal)— Hydrocephalus,    meningitis, 
hemorrhages  within,  brain  tumor,  thrombosis  of  sinus. 

(b)  Depressed — Atrophic    constitutional    diseases,    severe    diar- 
rhea, first  stages  of  meningitis. 

Tumors.     (About  the  head.)     Hematoma,  abscess,  sarcoma,  syphilis, 
encephalocele,  hydromeningocele,  hernia  cerebri. 
6  81 


82  DISEASES  OF  CHILDREN. 

Neck. 
Tumors.     (About  the  neck.) 
(a)  Parotitis. 
(6)   Lymph  node  hypertrophy. 

(c)  Thyroid  enlargement. 

(d)  Branchial  cleft. 

(e)  Congenital  cysts  (blood  cysts,  angiomata,  hygroma). 
(/)    Hematoma  (especially  of  the  sternomastoid). 

Face. 
Expression. 

(a)  Pain  (intermittent) — Colic,  dentition,  dysuria,  otitis,  bodily 

discomfort. 
(h)  Pain  (continuous) — Pneumonia,  pleurisy,  peritonitis. 

(c)  Pain   (on  handling) — Scurvy,    fracture,   dislocation,   rickets, 
spinal  paralysis,  meningitis,  neuritis,  rheumatism. 

(d)  Anxious — Obstructed  breathing  or  dyspnea  from  any  cause; 
heart  disease. 

(e)  Cretinoid — (Thick  lips,  protruding  tongue,  stolid). 

(/)    Sad — (spirituelle).     Tuberculosis  and  chronic  diseases. 
(g)   Disgust — Dyspepsia,  gastritis,  abdominal  disease. 
(h)  Senile — Marasmus,  syphilis,  internal  hydrocephalus. 
(i)    Pinched — (abdominal).     Peritonitis,  cholera  infantum,  pro- 
longed or  severe  diarrhea,  collapse. 
(;')    Foolish — Idiocy. 
(^•)  Stupid — (fish  mouth).     Adenoids. 

Mouth. 
Open  Mouth. 

Cretinism,  rickets,  idiocy,   coryza,  inflammation  of  the  throat. 

Lips. 

Enlarged. — Cretinism,  syphilis,  adenoids  and  hypertrophied  ton- 
sils, infection,  neoplasms. 
Fissures  and  Ulcerations. 

Syphilis,  stomatitis,  after  and  during  acute  infectious  diseases, 

injuries. 
Tongue. 

Enlarged. — Congenital,  cretinism,  idiocy,  inflamuiatory  processes, 

trauma,  infection. 

Fissures  and  Ulcers. — Syphilis,  caries  of  the  teeth,  tuberculosis, 

stomatitis,  ulcer  of  frenum. 


SUGGESTIVE  SCHEME  FOR  DIAGNOSIS.  83 

Enlarged  Papillce. — Strawberry  tongue  of  scarlet  fever,  diabetes, 
lymphatic  leukemia,  status  lymphaticus. 
Geographical. — Intestinal  fermentation,   tuberculosis. 

Gums. 

Swollen,  Bleeding  or  Spongy. — Gingivitis,  acute  infectious  diseases, 
scurvy,  congenital  heart  disease,  leukemia,  stomatitis,  difficult 
dentition,  caries  of  the  teeth,  neoplasms. 

Teeth. 

Syphilis  (Hutchinson's  teeth),  cretinism  (small  pointed),  severe 
chronic  diseases  (notches,  ridges,  rings).  Delayed  dentition; 
rickets,  syphilis  (in  infancy).  Chronic  diseases  of  infancy. — 
Loosening  and  shedding  in  scurvy,  mercury,  caries. 

Swallowing. 

(a)  Pseudo  dysphagia. 

Nasal  obstruction,  sore  mouth,  parotitis,  adenoids,  pyloric  steno- 
sis, anorexia. 

(6)  True  Dysphagia. 

Paralysis  of  soft  palate,  pharynx  or  tongue. 

Spasm  of  muscles  in  tetanus,  chorea,  strychnin  poisoning,  hysteria, 

Thomsen's  disease. 

Swellings  of  tonsils.     Peritonsillar  abscess.     Angina,  mediastinal 

glands,  thyroid,  thymus. 

Macroglossia. — Cretinism. 

Corrosion.     Cicatrix.     Heat,  drugs,  syphilis,  tuberculosis,  trauma, 

ulcer,  foreign  body. 

Congenital  Defects. — Atresia,  stenosis,  diverticula. 

Abnormalities  in  Breathing. 

1.  Mouth  Breathing  in  Nasal  Obstruction. 

(Noisy  breathing,  snoring)  narrowing  or  obliteration,  congenital 
obstruction,  cretinism,  syphilis,  deformities,  chondrodystrophy, 
adenoids,  polypus,  foreign  bodies,  hematoma,  tuberculosis,  lupus, 
abscess,  rhinitis  acute  and  chronic,  injuries. 

2.  Inspiratory  Dyspnea. 

(a)  Pharyngeal  Stenosis. — Enlarged  tonsils,  chronic  neoplasms, 
retropharyngeal  and  peritonsilar  abscess.  Phlegmon  diph- 
theritic, cold  abscess,  tuberculous  glands,  vertebral  caries, 
macroglossia,  ranula,  neoplasms  of  tongue  and  jaw. 


84  DISEASES  OF  CHILDREN. 

(b)  Laryngeal  Stenosis. — Diphtheria,  spasmodic  laryngitis  (croup), 
laryngo-spasm  with  crowing  inspiration,  tetany,  rickets, 
hydrocephalus,  enlarged  bronchial  glands,  status  lymphaticus, 
membrane  in  scarlet  and  measles,  tuberculosis,  syphilis,  neo- 
plasms, urticaria,  foreign  bodies,  drugs,  scalding,  corrosion, 
edema  glottis,  edema  from  renal  and  cardiac  disease,  goiter, 
paralysis. 

(c)  Tracheal  and  Bronchial  Stenosis. — Diphtheria,  enlarged  bron- 
chial glands,  thymic  disease,  goiter. 

3.  Expiratory  Dyspnea. 

Emphysema,  asthma,  spasm  of  inspiratory  muscles,  tetanus,  tet- 
any, epilepsy,  hysteria,  convulsions  (irritation  phrenic  nerve 
in  pericardial  effusion). 

4.''  Mixed  Dyspnea. 

Bronchitis,  pneumonia,  pulmonary  edema,  pleurisy,  tuberculosis, 
heart  disease,  the  anemias,  toxic,  and  acute  infectious  diseases, 
diabetic  coma,  uremia,  gas  poisoning,  heat  stroke,  organic  lesions 
of  pons  and  medulla,  tumors,  abscess  and  hemorrhages  of  brain, 
anterior  poliomyelitis  with  cerebral  symptoms. 

Chest. 

Shape. 

(a)  Barrel  Shape. — Emphysema,  pertussis,  asthma,  bronchiecta- 
sis, chronic  bronchitis,  pneumothorax. 

(6)  Contracted  Chest. — Rickets,  tuberculosis,  stenosis  of  upper 
respiratory  tract  as  adenoids  and  stenosis  of  larynx. 

(c)  Bulging  Sternum  (pigeon  breast). — Rickets,  heart  disease, 
pertussis,  stenosis  alone. 

(d)  Asymmetrical. — Pleural  effusions,  pneumothorax,  pleural 
adhesions,  scoliosis. 

(e)  Funnel  Shape. — Rickets,  intraabdominal  pressure. 
(/)  Harrison's  Groove. — Rickets. 

Tumors  of  Chest  Wall. 

(a)  Pointing  empyema,  caries  of  spine,  bronchial  glands,  periosti- 
tis. 

(6)  Breast — (Milk  distention,  septic  mastitis,  mumps,  true 
tumors.) 

(c)  Bulging  precordia,   heart  disease,  pericarditis. 

(d)  Hernia  of  lung. 


SUGGESTIVE  SCHEME  FOR  DIAGNOSIS.  85 

Abdomen. 

General  Enlargement  or  Prominent  Abdomen. 

(a)  Distention  with  Gas. — Dyspepsia,  gastritis,  pyloric  stenosis, 
intestinal  indigestion  and  dysentery,  intestinal  obstruction, 
constipation,  tuberculous  and  septic  peritonitis,  pneumonia, 
typhoid,  congenital  dilatation  of  colon,  obstructed  hernia, 
intestinal  perforation. 

(b)  Fluid.  (1)  Peritonitis  (chronic,  serofibrinous,  tuberculous, 
septic  (from  umbilicus),  gonorrheal,  pneumonic. 

(2)  Heart  disease  (uncompensated  heart  and  chronic  adhe- 
sive pericarditis). 

(3)  Kidney  diseases. 

(4)  Hepatic  diseases  (cirrhosis,  true  tumors,  degeneration). 

(5)  Portal  obstruction  (enlarged  glands,  adhesions). 

(6)  Grave  anemias. 

(c)  Constitutional  Diseases. — (Usually  from  weak  spine.)  Rickets, 
cretinism,  syphilis,  marasmus. 

(d)  Miscellaneous. — Pott's  disease,  curvature,  congenital  dis- 
location of  hip.     Hysteria. 

(e)  Enlarged  liver  and  spleen. 

Enlarged  Liver. 

(1)  Hyperemia  in  Sepsis. — Cardiac  and  pulmonary  affections. 

(2)  Toxic. — (a)  Alcohol,  phosphorus,  santonin. 

(6)   acute  infectious  diseases. 

(3)  Constitutional  Diseases. — Tuberculosis,  syphilis,  rickets,  ath- 
repsia. 

(4)  Cirrhosis. — (Acute  yellow  atrophy.) 

(5)  The  Anemias. — Leukemia,  pseudoleukemia,  splenic  anemia, 
Banti's  disease,  primary  splenomegaly. 

(6)  Abscess,  cysts  and  true  tumors. 

Enlarged  Spleen. 

(1)  Acute  infectious  diseases. 

(2)  Constitutional  diseases  (as  above). 

(3)  Hepatic,  cardiac  and  pulmonary  (as  above). 

(4)  The  anemias  (as  above). 

(5)  Abscess,  cysts  and  neoplasms. 

Localized  Tumors. 

(a)  Kidney. — ^Floating  kidney,  hydronephrosis,  pyelitis,  peri- 
nephritis, neoplasm,  cystic  kidney,  tuberculosis. 

(6)  Stomach   and   Intestines. — Pyloric   stenosis,    intussusception, 


86  DISEASES  OF  CHILDREN. 

appendicitis,  impacted  feces,  worms,  neoplasms,  congenital 
dilatation  of  colon, 
(c)    Miscellaneous. — Thickened  omentum    (tuberculous   peritoni- 
tis)   mesenteric   glands,   psoas   abscess,   encysted  peritoneal 
abscess,  distended  bladder. 
Tumors  of  Abdominal  Wall. 

Abscess,  hematoma,  hernia  (muscular). 
Umbilical  Region. 

(1)  Hernia  (of  omentum,  intestines,  bladder). 

(2)  Fungus  (granulations). 

(3)  Periumbilical  abscess. 

Inguinal  Region. 
Tumors  or  Enlargements. 

Hernia,  hydrocele  of  tunica  vaginalis  and  cord. 

Undescended  testicle. 

Orchitis,  mumps,  syphilis,  tuberculosis,  influenza,  trauma. 

Neoplasms. 

Varicocele. 

Delayed  Growth. 

(a)  Improper  feeding  and  digestion,  starvation,  pyloric  stenosis, 
marasmus. 

(b)  Cretinism,  rachitis,  idiocy,  infantilism,  osteomalacia,  micro- 
melia. 

(c)  Tuberculosis. 

(d)  Syphilis. 

(e)  Valvular  heart  disease. 
(/)    Progressive  paralysis. 

Hemorrhages. 
1.  General  Causes. 

(1)  Acute  Infectious  Diseases. — Pyemia,  septicemia. 

(2)  Toxic. — lodids,  mercury,  ergot,  belladonna,  phosphorus, 
antipyrin,  chloral,  arsenic,  food  poisoning,  snake  bites. 

(3)  Constitutional  Diseases. — Syphilis,  scurvy,  Bright's  disease, 
tuberculosis,  athrepsia,  cachexia. 

(4)  Purpura. — Purpura  simplex,  fulminans,  hemorrhagica  rheu- 
matica,  Henoch's  purpura. 

(5)  Blood  Diseases.  —  Hemophilia,  leukemia,  pseudoleukemia, 
splenic  anemia,  Banti's  disease,  severe  secondary  and  perni- 
cious anemia. 

(6)  Mechanical. — Injury,  pertussis,  epilepsy,  at  birth. 


SUGGESTIVE  SCHEME  FOR  DIAGNOSIS.  87 

2.  Special  Causes. 

(a)  Of  New-born.  —  Asphyxia,  obstetrical  operations,  deficient 
expansion  of  lungs,  sepsis,  syphilis,  hemophilia,  congenital 
disease  of  liver  and  bile  ducts. 

(6)   From  Nose. — 

(1)  In  new-born  as  above. 

(2)  Affections  of  mucous  membrane.  Traumatism,  foreign 
body,  acute  and  chronic  rhinitis,  adenoids,  polypus,  diph- 
theria, measles,  worms. 

(3)  Congestion,  prolonged  cough.  Cardiac  and  pulmonary 
afifections.     Overheating,  nephritis,  sinus  thrombosis. 

(4)  Prodromal,  in  acute  infectious  diseases. 

(5)  Vicarious  menstruation. 

(6)  Fractured  skull. 

(c)  Of  Stomach. — Gastric  ulcer,  chemical  erosions,  worms,  foreign 
body.  Occlusion  of  intestines,  swallowed  blood,  general 
causes  as  in  1. 

(d)  Rectum. — General  causes  and  new-born.  Severe  enteritis, 
gastric  and  intestinal  ulcer,  follicular  and  membranous  enteri- 
tis, worms,  intussusception  and  strangulation,  hemorrhoids, 
polypus,  anal  fissure,  condyloma,  prolapse  rectum,  injury 
with  enemata, 'etc.,  typhoid,  tuberculosis. 

Extremities. 
1.  Disturbances  of  Motion. 

(a)  Paralysis  or  Pseudoparalysis. — Anterior  poliomyelitis,  scurvy, 
syphilis,  rickets,  postdiphtheria,  cerebral  palsy,  neuritis,  birth 
palsy,  meningitis,  fracture,  epiphyseal  suppuration,  osteo- 
myelitis, spina  bifida,  transverse  myelitis,  progressive  mus- 
cular atrophy.     Landry's  paralysis. 

(6)  Inability  to  Walk  or  Walk  with  Limp. — (Any  of  the  above  pa- 
ralyses cited  in  (a) ).  Delayed  walking.  Tuberculosis  of  the 
hip,  knee,  ankle.  Pott's  disease,  osteomalacia,  congenital 
dislocation  of  the  hip,  rickets,  coxa  vara,  rheumatism,  mental 
deficiency,  idiocy,  hydrocephalus  and  microcephalus,  cretin- 
ism, w^eakness  after  disease  or  poor  nutrition,  progressive 
muscular  atrophy,  flat-foot,  improperly  fitted  shoes. 

(c)  Spastic  Extremities  (rigidity). — (Normal  in  early  infancy.) 
Gummata,  cerebral  hemorrhages,  sclerosis,  tumors,  spastic 
paraplegia,  acute  encephalitis.  Little's  disease,  hydrocephalus, 
meningitis,  lateral  sclerosis,  hereditary  ataxia,  tetany,  cata- 
lepsy, tetanus. 


»»  DISEASES  OF  CHILDREN. 

2.  Swellings. 

(a)  Joints. — Chronic  and  acute  polyarthritis.  (Rheumatic,  puru- 
lent, gonorrheic,  following  scarlet  fever  and  pneumonia). 
Tuberculosis  of  the  joints,  simple  effusion,  bursitis. 

(6)  Bones. — Rickets  (epiphyseal),  syphilis,  scurvy  (subperios- 
teal).    Osteomyelitis,  neoplasms.  -^ 

(c)  General  Enlargement. — Anasarca,  angioneurotic  edema,  sepsis, 
hydremia,  acromegaly,  elephantiasis,  erysipelas,  cretinism. 

3.  Hands. 

(a)  Dactylitis, — (Simple,   tuberculous,   syphilitic.) 
(6)   Clubbed  Fingers. — Heart  disease,  chronic  cough,  hepatic  cir- 
rhosis. 

(c)  Claw  Hand. — Ulna  paralysis,  progressive  atrophy,  lesions 
spinal  cord,  ischemic  paralysis. 

(d)  Purposeless  Involuntary  Movements. — Chorea  (infectious  and 
hereditary,  Huntington's).  Organic  brain  lesions  (hemi- 
plegia, tumors,  abscess  brain,  sclerosis  after  meningitis). 
Friedrich's  ataxia,  habit  spasm,  idiocy,  hysteria. 


SECTION  VI. 
INFANT  FEEDING. 


CHAPTER  XL 
THE  INFANT  FROM  THE  NUTRITIONAL   STANDPOINT.* 

Introduction. — It  is  coming  to  be  an  important  part  of  a  physician's 
work  to  look  after  the  feeding  of  infants,  and  as  much  if  not  more  knowl- 
edge is  required  to  do  this  successfully  than  is  called  for  in  writing 
prescriptions  for  drugs  for  diseases.  No  one  can  become  a  good  infant 
feeder  who  is  not  well-grounded  in  the  principles  of  nutrition,  partic- 
ularly as  they  apply  to  infants,  or  who  has  not  served  an  appren- 
ticeship under  a  successful  feeder  and  learned  the  art  of  infant 
feeding,  even  if  he  has  not  mastered  the  science.  As  a  principle  may 
oftentimes  be  applied  in  different  ways  and  as  methods  that  are  ap- 
parently contradictory  may  produce  essentially  the  same  results, 
a  section  will  be  devoted  to  the  elementary  principles  involved  in  the 
management  of  all  infants,  so  that  confusion  will  not  be  caused  by  the 
apparently  contradictory  statements  of  other  authors.  The  essential 
sameness  of  many  substances  and  procedures  which  are  to  all  appear- 
ances diametrically  opposed  to  each  other  will  then  be  recognized. 

The  Infant.— To  thoroughly  understand  the  management  of  in- 
fants one  must  fully  realize  the  position  of  the  infant  in  the  life  history 
of  a  human  being.  A  normal  life  history,  from  a  biological  standpoint, 
commences  at  conception  and  ends  at  death  due  to  old  age.  The  prob- 
lem of  nutrition  begins  when  the  fertilized  ovum  starts  to  divide  and 
form  additional  cells,  and  from  this  time  on  until  death  there  is  an  un- 
ceasing demand  for  food.  During  a  life  history  the  food  is  supplied  in 
many  different  forms,  and  as  the  organs  of  nutrition  change  in  the 
earlier  stages  of  development,  the  physical  properties  of  the  food 
change  also.  Fig.  25  is  intended  to  show  the  different  forms  of  food 
utilized  by  the  human  being  during  its  life  history  and  the  organs 
of  nutrition  used  at  different  stages  of  development.  In  the  earliest 
stages  the  food  is  supplied  from  the  yolk  of  the  ovum;  as  development 
progresses,  the  villi  of  the  chorion  appear  and  act  as  organs  of  nutri- 

*For  greater  details  in  reference  to  the  biology  of  this  subject,  see  "Theory 
and  Practice  of  Infant  Feeding,"  by  Dr.  H.  D.  Chapin.  Third  edition.  William 
Wood  &  Co. 

89 


90 


DISEASES  OF  CHILDREN. 


tion;  these  gradually  merge  into  the  placenta  which  derives  food  from 
the  maternal  blood;  at  birth  the  breasts  supply  food  in  the  form  of 
colostrum  for  a  few  days,  which  is  gradually  displaced  by  milk.  When 
the  milk  supply  naturally  fails,  toward  the  end  of  the  first  year,  the 
child  is  capable  of  digesting  some  forms  of  semisolid  food  such  as  its 
parents  eat,  and  continues  its  development  on  this  food. 


FIRST  NUTRITIVE  PERIOD 


1ST 

2ND 

3RD 

•4TH 

OVUM 

CHORION 

PLACENTA 

BREASTS 

YOLK 

YOLK  AND  SERUM 

MATERNAL  BLOOD 

COLOSTRUM  AND  MILK 

SECOND  NUTRITIVE  PERIOD 


(5 


5TH 

MILK.  BREAD, CEREALS, EGGS 
Fig.  25 


S0UP.FISH.MEAT.VEGETABLE5,FRUIT.NUTS 
Nutritive  life  history. 


Life  Divided  into  Two  Nutritive  Periods. — From  the  illustrations  in 
Fig.  25  it  will  be  observed  that  the  life  of  a  human  being  is  sharply 
divided  into  two  parts:  First,  that  which  is  marked  by  the  food  being 
derived  entirely  from  the  mother;  second,  that  in  which  none  of  the 
food  is  supplied  by  the  mother.  It  will  also  be  noticed  that  during  the 
period  in  which  the  food  is  supplied  exclusively  by  the  mother,  there 
is  a  rapid  change  in  the  form  and  complexity  of  the  organization  of 
the  fetus  or  infant,  and  that  the  form  in  which  the  mother  furnishes 
the  food,  the  organs  through  which  she  supplies  it,  and  the  organs  of 


THE  INFANT  FROM  THE  NUTRITIONAL  STANDPOINT. 


91 


nutrition  of  the  fetus  and  infant  undergo  great  changes.  In  a  word, 
the  mother  changes  the  food  to  suit  the  condition  and  organs  of  the 
developing  infant,  and  not  until  the  digestive  tract  is  developed  sufii- 
cientl}''  to  be  able  to  utilize  semisolid  food  does  the  normal  mother 
cease  to  nourish  her  offspring  with  special  forms  of  food. 

The  second  nutritive  period  begins  when  the  child  is  able  to 
secure  enough  nutriment  from  semisolid  food,  and  this  period  is 
marked  more  by  general  increase  in  size  than  by  profound  structural 
changes  or  the  development  of  new  nutritive  functions. 


Table  Showing  Derivation  of  Tissues  of  Man  Weighing  180  Pounds. 

{Schematic.) 
Conception  to  weaning  (first  nutritive  period): 
Ovum       1 

Chorion    [  supply 8  pounds  (birth  weight). 

Placenta  J 

Breasts  supply 12  pounds 

20  pounds  (weight  at  weaning). 
Weaning  to  maturity  (second  nutritive  period): 
Milk,  eggs,  cereals,  meat,    1  ,  .^.^ 

fish  and  vegetables  /  ^^PP^>' i^ 

Total 180  pounds  (weight  at  maturity). 

Essential  Unity  of  Foods. — When  all  forms  of  food,  including 
mother's  milk,  are  subjected  to  chemical  analysis  they  are  found  to  be 
composed  of  ingredients  which  fall  into  five  groups :  Proteins,  often- 
times termed  proteids,  which  form  the  tissues; 
mineral  matter  which  is  necessary  for  bone 
formation,  and  also  in  lesser  quantities  to 
replace  metabolic  waste;  fats  and  carbohy- 
drates which  supply  the  energy;  and  water. 
The  great  difference  in  foods  at  different  ages 
is  not  one  of  composition,  hut  of  form. 

Foods  of  the  First  Nutritive  Period. — The 
mother  supplies  food  to  her  offspring  in  six 
different  forms:  First,  the  yolk  of  the  ovum; 
next  the  fluid  in  which  the  ovum  is  bathed; 
then  that  which  is  supplied  in  a  form  suited 
for  assimilation  by  the  chorion;  and  then 
by  blood  which  circulates  through  the  pla- 
centa. When  birth  occurs,  the  food  is  sup- 
plied through  the  breasts  in  two  forms,  at  first  colostrum  and  finally 
as  milk. 

Each  of  these  forms  of  food  is  specially  adapted  to  the  infant 
at  the  time  it  is  furnished,  and  as  soon  as  the  infant  outgrows  one 
form  of  food  another  is  supplied. 


Fig.  26. — Mammary 
fetus,  of  kangaroo;  life 
size.  {Parker  and  Has- 
well.) 


92  DISEASES  OF  CHILDREN. 

The  Infant  a  Mammary  Fetus. — While  the  infant  is  looked  upon 
as  a  fetus  until  birth,  it  is,  in  a  broader  sense,  a  fetus  until  it  is  capable 
of  subsisting  on  soft  food,  or,  in  other  words,  until  its  digestive  appa- 
ratus is  developed.  Fig.  26  shows  the  fetus  of  the  kangaroo.  This 
animal  has  no  placental  connection  with  its  mother;  it  is  born  in  an 
exceedingly  rudimentary  state  of  development,  and  then  grows  fast 


Fig.  27. — Head  of  mammary  fetus,  hemisected  to  show  adaptation  of  teat  to 
mouth.     {From  a  specimen,  Columbia  University.) 

to  the  nipple,  at  which  it  develops  from  the  size  of  a  young  mouse 
to  a  weight  of  about  seven  pounds,  when  it  is  able  to  secure  food  for 
itself  and  becomes  independent  of  its  mother.  In  the  early  stages 
of  the  mammary  development  of  the  kangaroo  the  mother  ejects  the 
food  into  the  esophagus  which  at  this  time  has  no  connection  with  the 
air  passages  (Fig.  27),  As  the  development  advances  the  fetus 
ceases  to   be   adherent   to   the   nipple   and  obtains   nourishment  by 


THE  INFANT  FROM  THE  NUTRITIONAL  STANDPOINT. 


93 


sucking.     At  one  time  this  type  of  animal  predominated,  but  now 
placental  forms  so  far  outnumber  them  that  they  have  become  rare. 

If  the  infant  was  born  about  the  time  the  placenta  develops  and 
then  became  adherent  to  the  nipple  it  would  be  nourished  much  like 
the  young  kangaroo,  and  the  importance  and  place  of  breast-feeding 
would  be  self-evident.  The  young  of  implacentals  are  still  in  the 
fetal  stage  at  birth,  and  also  after  the  mouth  ceases  adhering  to  the 
nipple,  which  corresponds  to  the  time  of  birth  or  when  the  placenta 
separates  from  the  mother  in  placental  animals.  For  some  time  after- 
ward they  depend  upon  the  mother  for  nourishment.  Therefore  from 
a  nutritive  standpoint  the  infant  is  as  much  a  fetus  as  is  an  impla- 


FiG.  28. — C(>lot;trum  corpuscles. 
{Jewett.) 


Fig.  29.- 


-Normal  human  milk. 
(Jewett.) 


cental  animal  after  it  is  developed  sufficiently  to  suck,  and  this  fact 
should  be  kept  in  mind. 

Breast  Secretions :  Specialized  Foods. — From  the  illustrations  in 
Fig.  25  it  is  plain  that  before  birth  the  form  of  the  food  supplied  by 
the  mother  and  the  method  of  furnishing  it  change  to  suit  the  state  of 
development  of  the  fetus;  and  as  at  birth  the  digestive  organs  of  the 
infant  are  not  fully  developed,  it  may  be  concluded  that  in  some  way 
the  breast  secretions  are  peculiarly  adapted  for  that  part  of  the  first 
nutritive  period  in  which  the  digestive  tract  is  developing. 

Composition  and  Properties  of  Breast  Secretions. — The  first 
secretion  of  the  breasts  or  mammary  glands  after  the  infant  or  young 
animal  is  born  is  called  colostrum.  Chemical  analysis  shows  it  to  be 
composed,  like  all  foods,  of  proteins,  mineral  matter,  fats,  carbohy- 
drates, and  water. 

Upon  boiling,  colostrum  coagulates,  owing  to  a  large  portion  of 


94 


DISEASES  OF  CHILDEEN. 


the  protein  being  in  the  form  of  albumin.  It  is  also  distinguished  by 
the  presence  of  colostrum  corpuscles  (Fig.  28),  In  the  course  of  a 
few  days  after  birth  the  character  of  the  breast  secretion  undergoes  a 
complete  and  radical  change.  The  later  secretion  is  milk,  which  is  also 
composed  of  protein,  mineral  matter,  fats,  carbohydrates,  and  water, 
but  it  will  not  coagulate  when  boiled,  showing  there  has  been  a  change 
in  the  character  of  the  protein,  and  the  colostrum  corpuscles  are 
absent.  From  these  facts  it  is  evident  that  chemical  analysis  throws 
little  light  on  the  properties  of  either  colostrum  or  milk,  except  to 
show  that  they  are  composed  of  the  basic  food  elements. 

As  the  characteristic  feature  of  nutrition  during  the  first  nutritive 
period  is  the  adaptation  of  the  form  of  the  food  by  the  mother  to  the 


Teeth  and 
salivary  glands. 


Stomach. 


Intestines. 


Fig.  30. — Development  of  human  digestive  tract. 
(Allen  Thompson  and  Wiedersheim.) 


organs  of  nutrition  of  the  fetus,  which  are  constantly  undergoing 
change,  it  is  evident  that  the  way  to  acquire  a  knowledge  of  the  proper- 
ties of  the  breast  secretions  is  to  study  them  in  the  relations  to  the 
infant's  digestive  organs. 

Development  of  the  Digestive  Tract. — At  birth  the  digestive  organs 
are  quite  different  both  anatomically  and  physiologically  from  those 
of  the  adult.  Teeth  are  absent,  which  in  the  adult  reduce  the  food 
to  a  state  of  fine  subdivision,  to  fit  it  for  the  stomach,  and  the  gastric 
secretions  particularly  are  not  like  those  of  the  adult,  and  in  some 
animals  the  stomach  is  not  fully  formed.  During  the  colostrum  period 
there  is  little  gastric  secretion,  but  when  the  mother  secretes  milk, 
the  rennet  ferment  or  rennin,  which  is  closely  allied  to  pepsin,  is 
secreted  in  the  stomach.     Rennin  prepares  the   milk  for  stomach 


THE  INFANT  FROM  THE  NUTRITIONAL  STANDPOINT. 


95 


digestion  by  the  infant  in  much  the  same  manner  as  teeth  prepare  the 
food  for  digestion  later  in  life.  That  is,  rennin  acts  upon  a  portion 
of  the  milk  and  changes  it  from  a  fluid  into  a  semisolid  which  has  on 
a  small  scale  much  of  the  physical  property  and  texture  of  the  chewed 
food  of  the  adult.  Until  pepsin  and  acid  are  secreted,  true  gastric 
digestion  does  not  take  place  and  the  solid  remains  very  soft;  but 
when  acid  appears  it  in  some  way  combines  with  the  solidified  milk, 
rendering  it  more  solid  and  fitting  it  for  digestion  by  pepsin.  Thus 
it  is  that  the  first  solid  food  for  the  undeveloped  digestive  organs  is 
produced  from  the  specialized  food  supplied  by  the  mother,  and  its 
digestive  properties  are  altered  or  adapted  to  the  stomach  by  the 
gastric  secretions. 


Fig.  31. — Stomach  of  different  milk  secreting  animals.     (Wiedersheim.) 


Comparative   Anatomy   and   Physiology   of   Digestive   Organs. — 

When  the  digestive  organs  of  the  lower  mammals  are  compared  it 
is  found  they  differ  greatly  both  in  structure  and  in  the  methods 
by  which  they  carry  on  the  digestive  processes.  All  animals  digest 
proteins,  mineral  matter,  fats  and  carbohydrates,  and  the  chemical 
changes  that  take  place  in  digestion  are  essentially  the  same  in  all 
forms  of  animal  life,  but  methods  of  digestion  show  wide  differences. 
In  the  early  fetal  stages  the  digestive  tracts  of  all  mammals  are  very 
much  alike,  but  as  development  proceeds,  anatomical  differences  are 
observed  which  become  pronounced  as  maturity  is  approached.  There 
are  as  wide  differences  in  the  digestive  organs  of  animals  as  there  are 
in  the  forms  of  their  limbs  and  feet,  and  these  differences  assume  great 
importance  when  it  comes  to  selecting  food  for  different  species.     From 


96  DISEASES  OF  CHILDREN. 

practical  experience  in  feeding  many  kinds  of  animals  at  experiment 
stations  the  following  principle  has  been  deduced:  the  food  must  he 
adapted  to  the  species. 

Comparative  Mammary  Secretions. — As  far  as  known,  all  mam- 
mals secrete  colostrum  for  a  few  daj's  after  birth  takes  place,  and 
this  secretion  is  followed  gradually  by  milk,  but  the  milks  of  different 
species  show  wide  differences  in  their  properties.  When  they  are 
subjected  to  chemical  analysis,  it  is  found  they  all  agree  in  being  com- 
posed of  proteins,  mineral  matter,  fats,  carbohydrates  and  water,  al- 
though the  proportions  of  these  ingredients  are  not  the  same  in  all 
kinds  of  milk  or  in  the  milk  of  different  individuals  of  the  same  species. 
To  one  who  is  not  familiar  with  the  methods  of  milk  and  food  analyses 
it  might  appear  from  this  that  the  differences  between  milks  of  different 
species  were  due  merely  to  the  varying  proportions  of  the  food  elements 
present,  and  for  a  time  this  was  the  belief  held  by  some  of  the  foremost 
pediatricians.  But,  when  it  was  known  how  little  idea  of  the  prop- 
erties of  a  food  is  shown  by  the  report  of  its  chemical  analysis,  the 
limited  value  of  food  analyses  in  infant  feeding  was  appreciated. 
The  terms  proteins,  mineral  matter,  fats,  carbohydrates,  and  water 
are  about  as  definite  as  the  terms  wood,  stone,  glass,  and  metal  used 
in  describing  the  construction  of  a  house,  and  comparing  foods  accord- 
ing to  the  proportions  of  the  elements  present  is  about  as  useful  a 
procedure  as  comparing  buildings  by  their  composition. 

However,  it  must  not  be  supposed  that  a  chemical  analysis  of 
food  or  milk  has  no  value,  for  it  is  of  great  importance,  but  its  true 
value  should  be  recognized  and  not  overestimated. 

The  proper  way  to  compare  milks  for  infant  feeding  is  to  see  how 
they  react  to  rennin,  pepsin,  and  acid,  and  how  they  compare  in  compo- 
sition. Milks  of  different  species  when  so  compared  show  great  differ- 
ences, although  they  may  have  identically  the  same  composition ;  that  is, 
be  composed  of  the  same  quantities  of  proteins,  mineral  matter,  fats, 
carbohydrates,  and  water.  Human  milk  is  changed  into  a  semi- 
solid, finely  divided  mass  by  rennin,  pepsin  and  acid;  cow's,  goat's, 
and  sheep's  milk  into  a  solid  mass  which  is  of  the  same  volume  as  the 
milk;  mare's  and  asses'  milk  into  a  fluid  jelly.  This  results  from  the 
action  of  rennin  on  a  portion  of  the  proteins  generically  termed  casein, 
or  by  some  caseinogen.  When  the  digestive  organs  of  the  various 
animals  are  compared  it  is  observed  they  are  not  alike  either  in  form 
or  in  the  manner  in  which  they  perform  the  digestive  function,  and  it 
is  found  that  the  mother's  milk  is  digested  in  much  the  same  manner 
as  the  food  will  be  digested  after  weaning,  so  the  reason  for  the  differ- 
ent  physical   properties  of   the  various    milks  after  they  have   been 


THE  INFANT  FROM  THE  NUTRITIONAL  STANDPOINT.  97 

acted  upon  by  the  rennin  ferment  is  apparent,  and  the  fact  that 
mother's  milk  is  the  ideal  food  for  any  young  animal  becomes  self- 
evident.  It  is  Nature's  way  of  applying  the  rule — the  food  must  be 
adapted  to  the  species. 

If  the  peculiar  adaptation  of  the  milk  to  the  digestive  organs 
was  not  enough  proof  of  the  superiority  of  mother's  milk,  it  would 
be  found  in  the  fact  that  the  general  composition  of  the  milk  of  each 
species  of  animal  is  such  that  the  milk  is  adapted  to  the  rate  of  growth 
of  the  young.  Animals  that  grow  rapidly  need  larger  quantities  of 
proteins  than  those  which  grow  more  slowly  and  the  mothers  of 
animals  whose  growth  is  rapid  secrete  milk  much  richer  in  proteins 
than  mothers  of  animals  whose  growth  is  slower. 

In  practical  feeding  it  is  found  that  milks  of  different  species 
are  not  interchangeable  from  a  digestive  standpoint,  although  they  are 
all  highly  nutritive,  but  the  reason  was  not  discovered  until  infant 
feeding  was  studied  from  the  standpoint  of  milk  as  a  specially 
adapted  food,  and  the  subject  was  considered  from  a  biological  stand- 
point. 

Chemical  and  Biological  Standards  in  Infant  Feeding.^ — In  the 
early  days  of  scientific  infant  feeding  it  was  believed  that  the  differ- 
ences between  all  milks  lay  in  the  relative  quantities  of  proteins, 
mineral  matter,  fats,  carbohydrates,  and  water  of  which  they  were  com- 
posed and  in  their  reaction  to  litmus-paper,  and  that  milks  could  be 
made  interchangeable  by  readjusting  their  percentage  composition 
and  altering  their  reaction  to  litmus.  For  a  long  time  this  teaching  was 
thought  to  be  correct,  but  it  began  to  be  observed  that  it  was  often 
not  followed  in  practice,  and  it  was  then  taught  that  the  great  differ- 
ences between  milks  lay  in  the  relative  proportions  of  casein  and  albu- 
min which  made  up  the  proteins  of  milk.  For  a  time  this  teaching 
was  accepted  by  many,  but  it  was  found  that  caseins  differed  and 
that  the  term  casein  was  about  as  definite  as  the  term  wood.  By  a 
play  on  words  all  milks  could  be  made  alike  on  paper,  but  actually 
they  were  different. 

There  have  been  used  from  time  to  time  various  methods  of 
making  cow's  milk  agree  with  infants,  such  as  adding  lime-water,  bi- 
carbonate of  sodium,  citrate  of  sodium,  and  peptonizing  materials, 
which  have  produced  chemical  changes,  each  of  which  has  been 
claimed  to  make  cow's  milk  like  human  milk.  These  methods  have 
been  confusing  and  contradictory  and  have  made  the  whole  subject 
chaotic.  The  aim  has  been  to  make  human  milk  by  chemical  means 
and  the  standards  used  in  feeding  until  recently  have  been  purely 
chemical.  But  as  the  effects  of  the  different  methods  in  practice  have 
7 


98  .  DISEASES  OF  CHILDREN. 

been  studied  it  has  been  found  that  they  do  not  make  human  milk, 
but  either  change  the  character  of  the  proteins  of  cow's  milk,  or  alter 
the  action  of  the  digestive  secretions  of  the  infant  on  the  milk,  so  in 
reality  while  the  theory  has  been  that  chemical  changes  were  utilized 
to  make  human  milk  of  cow's  milk,  practice  has  been  along  the  line  of 
adapting  food  to  the  infant.  Theory  and  practice  have  been  diamet- 
rically opposed  and  naturally  great  confusion  was  the  result. 

Since  the  recognition  of  the  fact  that  it  is  impossible  to  make 
human  milk  from  other  substances  as  yet,  and  that  the  practice  is  to 
adapt  food  to  the  infant,  the  biological  standard  of  feeding  has  as- 
sumed greater  importance  and  makes  theory  and  practice  coincide. 

This  standard  or  principle  may  be  stated  as  follows: 

At  all  stages  of  life  the  food  must  be  composed  of  proteins,  mineral 
matter,  fats,  carbohydrates,  and  water. 

These  elements  exist  in  a  great  variety  of  forms  which  are  equally 
nutritious,  but  are  not  equally  adapted  for  the  digestive  organs  at  all 
ages,  or  for  all  species  of  animals,  as  their  digestive  organs  are  not  alike. 

The  peculiarities  of  the  digestive  organs  must  be  first  considered,  and 
after  this  has  been  done  food  must  be  selected  that  is  adapted  for  the 
particular  digestive  tract. 

After  such  a  food  has  been  found  its  composition  must  be  looked 
after  so  that  enough  of  the  elements  necessary  to  produce  proper  groicth 
and  development  may  be  assured. 

Under  this  standard  any  procedure  is  scientific,  provided  it  is 
employed  wath  the  understanding  of  its  purpose,  but  if  it  is  not  one 
that  cannot  be  continuously  used  without  danger  to  the  general  well 
being  of  the  infant  it  must  be  looked  upon  as  a  temporary  expedient 
and  the  patient  not  dismissed  until  on  a  proper  diet. 

In  the  treatment  of  practical  feeding  this  plan  will  be  followed, 
and  the  prominent  position  heretofore  given  to  the  supposed  chemical 
differences  between  human  milk  and  other  foods  will  not  be  found  in 
this  work.  The  chemical  side  of  feeding  will  be  subordinated  to  the 
physiological  aspect,  for  in  practice  all  that  the  chemical  composition 
of  a  food  shows  is  its  possible  nutritive  value,  its  actual  value  for  each 
infant  being  a  subject  for  determination  by  experiment  with  the 
infant. 

Recapitulation. — The  main  points  to  be  kept  in  mind  in  infant- 
feeding  are: 

The  infant  should  be  looked  upon  as  a  mammary  fetus. 

The  mother's  breast  secretions  are  specialized  forms  of  food, 
adapted  to  the  developing  digestive  organs. 

Milks  of  lower  animals  and  table  food  are  as  nutritious  as  mother's 


THE  INFANT  FROM  THE  NUTRITIONAL  STANDPOINT.  99 

milk,  but  are  not  adapted  to  the  undeveloped  condition  of  the  infant's 
digestive  tract. 

The  chemical  composition  of  a  food  shows  nothing  concerning  its 
suitability  for  any  animal  and  is  not  of  first  importance. 

The  value  of  foods  for  individuals  cannot  be  judged  by  comparing 
their  chemical  composition. 

Foods  may  be  "chemically  right  but  practically  wrong." 

The  food  elements  required  by  all  infants  are  the  same,  but  the 
form  in  w^hich  they  are  to  be  presented  must  be  determined  for  each 
infant  by  experiment. 

No  infant  is  a  law  unto  itself  except  concerning  the  form  in  which 
it  prefers  its  food. 


CHAPTER  XII. 
BREAST-FEEDING. 

Importance  of  Breast-feeding. — Reference  to  Fig.  25  on  page  90 
will  show  that  the  breast  secretions  are  the  last  of  a  series  of  specially 
suitable  forms  of  food  supplied  by  the  mother  during  the  period  in 
which  the  organs  and  their  functions  are  developing  in  the  infant. 
The  breast  secretions  are  furnished  during  the  time  the  infant's  diges- 
tive apparatus  is  developing,  and  serve  a  purpose  in  addition  to  supply- 
ing nourishment.  The  secretions  of  the  breasts  adapt  themselves 
to  the  increasing  strength  of  the  digestive  organs,  and,  instead  of  these 
organs  finding  their  work  easier  as  they  become  stronger,  they  find 
the  digestive  work  increases  as  their  digestive  capacity  becomes 
greater.  This  is  brought  about  by  an  alteration  in  the  physical 
properties  of  the  mother's  milk  in  the  stomach  by  the  infant's  gastric 
secretions  before  true  digestion  commences.  The  rennin,  pepsin 
and  acid  of  the  stomach,  as  they  successively  appear,  produce  pro- 
found changes  in  the  physical  condition  of  the  milk.  When  rennin 
acts  alone,  as  it  does  in  very  early  infancy,  the  milk  becomes  a  fluid 
jelly;  but  later  on  when  pepsin  and  acid  appear  the  milk  is  changed 
into  a  mass  having  much  of  the  consistency  of  well-chewed  food,  and 
which  should  be  looked  upon  as  its  prototype.  It  is  thus  that  the 
digestive  organs  are  prepared  to  digest  semisolid  food  about  the 
twelfth  month,  when  weaning  naturally  takes  place.  In  addition 
to  this  interesting  and  important  property  of  the  mother's  milk,  it 
generally  contains  the  food  elements  in  the  proportions  and  forms 
best  suited  for  proper  nutrition  of  the  infant. 

It  is  not  a  difficult  matter  to  bring  together  the  food  elements  in 
the  same  quantities  as  are  found  in  any  specimen  of  breast  milk,  or 
colostrum,  but  even  when  derived  from  milk  of  lower  animals  the 
food  does  not  have  the  delicate  properties  of  the  breast  secretions,  and 
it  is  often  contaminated  or  has  undergone  bacterial  changes. 

While  many  infants  are  successfully  fed  on  substitutes  for  breast 
secretions,  such  feeding  should  not  be  attempted  until  every  effort 
to  secure  breast-feeding  has  failed.  An  infant  that  is^fed  artificially 
is  in  reality  a  premature  infant,  for  breast-feeding  belongs  in  the  same 
category  as  maternal  feeding  through  the  placenta. 

The  death  rate  is  much  higher  among  artificially  fed  infants  than 

100 


BREAST-FEEDIXG.  101 

among  those  breast-fed,  and  in  hot  weather  when  bacterial  changes 
in  the  food  are  greatest  the  loss  of  artificially  fed  infants  is  several 
times  greater  than  during  the  colder  seasons,  while  the  increase  in 
death  rate  among  breast-fed  infants  is  slight. 

Every  consideration  shows  the  advantage  of  employing  the 
maternal  method  of  nutrition  while  the  infant's  digestive  organs  are 
developing,  and  breast-feeding  should  always  be  advocated  unless 
contraindicated  (see  p.  107). 

Preparation  for  Maternal  Feeding. — ^For  some  months  before 
delivery,  the  nipples  should  be  treated  so  as  to  toughen  them  and  thus 
prevent  tenderness  or  fissure  when  the  infant  uses  them.  This  is 
done  by  gently  rubbing  them  between  the  thumb  and  fingers.  De- 
pressed or  misshaped  nipples  may  thus  be  made  usable,  and  the 
comfort  of  the  mother  will  also  be  conserved. 

Management  of  Breast-feeding. — When  the  mother  is  enough 
rested  after  delivery  the  infant  should  be  offered  each  nipple.  If  it 
does  not  seem  satisfied  and  becomes  fretful  or  restless,  a  teaspoonful 
or  two  of  boiled  water  may  be  given.  This  will  quiet  the  infant  and 
helps  to  flush  out  the  digestive  tract  and  kidneys. 

For  the  first  day  or  two  the  infant  may  be  offered  the  breast 
every  three  hours  during  the  day  and  twice  during  the  night,  at 
four-  to  six-hour  intervals.  After  this  it  should  be  nursed  every  two 
hours  during  the  day  and  once  or  twice  at  night. 

When  the  supply  of  milk  is  sufficient  the  infant  will  suck  for 
fifteen  to  twenty  minutes  and  then  drop  off  to  sleep.  If  after  having 
the  nipple  twenty  to  thirty  minutes  the  infant  seems  restless  and 
unsatisfied  it  may  be  concluded  that  the  milk  supply  is  insufficient. 
A  weighing  before  and  after  nursing  may  also  help  to  determine 
whether  the  amount  has  been  sufficient.  After  the  first  few  weeks 
such  a  test  should  show  an  increase  in  weight  of  between  two  and 
three  ounces. 

If  under  such  management  the  infant  has  soft  yellow  stools  with 
no  pronounced  signs  of  indigestion  and  gains  steadily  in  weight,  it  may 
be  considered  as  doing  well  and  requires  no  further  attention. 

Regularity  of  Feeding  Important. — One  of  the  most  fruitful  causes 
of  indigestion  in  breast-fed  infants  is  feeding  at  irregular,  and  especially 
at  short  intervals.  Sometimes  a  fresh  feeding  is  taken  into  the  stomach 
before  the  previous  meal  has  been  digested  which  is  bad  enough; 
but  in  addition  to  this,  the  irregularity  in  nursing  has  a  profound  effect 
on  the  composition  of  the  mother's  milk. 

If  the  intervals  between  nursings  are  long  there  will  he  a  large 
quantity  of  rather  poor  milk;  but  when  the  milk  is   drawn  at  short 


102  DISEASES  OF  CHILDREN. 

\ 

intervals  it  has  the  effect  of  reducing  the  quantity  and  greatly  in- 
creasing the  percentage  of  fat,  the  other  ingredients  not  being  affected 
to  any  great  extent.  An  excess  of  fat  in  the  food  is  apt  to  produce 
vomiting,  and  an  abnormal  gastric  secretion  may  follow,  causing  the 
milk  to  curd  or  solidify  abnormally;  hence  it  is  not  difficult  to  see 
why  frequent  nursing  causes  digestive  disturbance.  When  milk  is 
drawn  at  regular  intervals  it  has  practically  the  same  composition, 
unless  the  mother  has  been  subjected  to  influences  that  derange  her 
nervous  system.  These  may  profoundly  alter  the  character  and  com- 
position of  her  milk  and  produce  great  disturbances  in  the  infant. 
It  is,  therefore,  of  the  greatest  importance  to  have  the  mother 
regular  in  her  own  habits  and  free  from  excitement,  and  that  the  infant 
be  fed  at  regular  hours.  It  will  be  helpful  if  the  mother  is  given  direc- 
tions for  feeding  by  the  clock,  as  at  5,  7,  9,  11  A.  M.;  1,  3,  5,  7,  9P.  M., 
and  once  during  the  night  in  occasional  cases. 

Milk  Agrees,  Flow  Scanty. — When  the  mother's  milk  agrees  with 
the  infant,  but  is  not  sufficient  in  quantity  to  cause  it  to  gain  in 
weight  steadily,  attempts  should  be  made  to  increase  the  flow,  and 
when  these  are  not  successful,  mixed  feeding,  that  is,  part  breast 
and  part  artificial  feeding  must  be  employed. 

If  the  mother  is  to  secrete  sufficient  milk  she  must  digest  and 
assimilate  a  liberal  supply  of  food  herself,  for  unless  she  does  this  the 
milk  will  be  produced  from  her  own  tissues  and  she  will  lose  in  weight. 
The  diet  of  the  mother  should  consist  of  simple,  easily  digested  food 
in  liberal  quantity  milk,  eggs,  and  thoroughly  cooked  cereals  being 
the  mainstay.  Tea  and  coffee  should  be  withheld  or  used  sparingly, 
cocoa  or  chocolate  being  given  in  their  place. 

Southworth,  who  has  devoted  much  attention  to  this  matter, 
recommends  the  use  of  cornmeal  gruels  to  be  taken  between  meals  as  a 
means  of  increasing  and  conserving  a  scanty  flow  of  breast  milk. 
When  cornmeal  gruel  is  not  relished,  oatmeal  gruel  may  be  substituted. 
The  gruels  are  made  as  follows: 

Two  to  four  heaping  tablespoonfuls  of  yellow  cornmeal  or  rolled  oats  are 
placed  in  one  quart  of  cold  water  in  a  double  boiler  and  the  water  in  the  boiler 
is  kept  boiling  for  two  or  three  hours.  The  gruel  is  then  strained  through  a 
coarse  wire  strainer  and  enough  boiling  water  is  added  to  make  one  quart  of 
gruel.  The  gruel  should  be  well  salted.  It  is  often  advantageous  to  add  an 
equal  quantity  of  milk. 

A  pint  of  such  gruel  is  to  be  taken  about  ten  o'clock  in  the  morn- 
ing and  again  at  about  three  in  the  afternoon.  The  gruel,  when  dex- 
trinized,  supplies  energy  food  in  a  form  quickly  assimilable,  and  the 
coarse  particles  of  the  gruel  undoubtedly  promote  normal  action  of 


BREAST-FEEDING.  103 

the  bowels  and  thus  promote  the  general  well-being  of  the  mother  and 
.incidentally  that  of  the  infant.  When  there  is  anemia  iron  should  be 
administered. 

Elimination  of  Drugs  and  Excretory  Products  in  Milk. — It  is  a 
well-known  fact  that  some  substances  pass  into  the  milk  from  the 
mother's  system  which  may  unfavorably  affect  the  infant.  Consti- 
pation of  the  mother  will  affect  the  infant  unfavorably,  and  under  cer- 
tain conditions  urea  in  appreciable  quantities  finds  its  way  into  the  milk. 
When  the  mother  is  constipated  and  the  use  of  cornmeal  gruel  does  not 
overcome  the  condition,  cascara  should  be  given. 

Great  care  must  be  exercised  in  giving  drugs  to  nursing  women, 
as  they  may  be  excreted  in  their  milk.  Morphin,  mercury,  quinin, 
iodid  of  potassium  and  similar  preparations  should  be  given  cauti- 
ously and  their  effects  watched. 

Milk  Plentiful,  but  Disagrees  with  Infant. — As  a  general  rule,  the 
milk  of  the  mother  will  agree  wdth  her  infant.  However,  there  are 
some  women  whose  milk  may  at  times  be  excessively  rich  in  all  of 
its  elements  or  which  may  fluctuate  widely  in  the  amount  of  fat 
present  or  have  properties  that  make  it  unacceptable  to  the  infant. 

If  the  milk  agrees  Avith  the  infant  for  a  time  and  then  suddenly 
disagrees  the  probabilities  are  that  the  mother  has  been  subjected  to 
excitement  of  some  kind;  it  may  be  worry,  fright,  anger,  grief,  or  loss 
of  sleep  that  has  made  her  irritable.  Such  influences  will  produce 
sudden  changes  in  the  character  of  milk  and  alter  its  digestive  proper- 
ties. It  is  well  known  that  the  milk  of  a  cow  that  has  been  overheated, 
driven  rapidly,  or  made  irritable  by  flies  or  dogs  will  not  react  nor- 
mally to  rennin  and  acid.  The  changes  brought  about  by  these 
nervous  influences  are  more  than  variation  in  percentage  composi- 
tion, and  cannot  be  detected  by  chemical  analysis.  The  remedy 
in  this  class  of  cases  is  to  remove  all  causes  of  anxiety  and  nervous 
disturbance,  and  have  the  mother  sleep  in  another  room  so  that  she 
shall  not  be  disturbed  by  the  infant's  crying.  Pleasant  surroundings, 
and  moderate  daily  exercise  in  the  fresh  air  are  also  indicated. 

Sometimes  the  milk  of  one  breast  is  perfectly  satisfactory  while 
that  of  the  other  causes  disturbance.  In  such  cases  the  remedy  is  to 
secure  all  of  the  feedings  from  the  good  breast  if  possible  until  the 
other  one  secretes  normal  milk. 

When  the  milk  disagrees  from  the  start  and  the  mother  seems 
healthy  it  is  possible  that  the  trouble  is  caused  by  the  milk  being  too 
rich,  the  result  of  overeating  on  the  part  of  the  mother.  At  any  rate 
it  is  helpful  in  all  of  these  cases  where  the  milk  disagrees  to  make  an 
examination  of  it,  as  will  be  explained  in  the  next  paragraph. 


104  DISEASES  OF  CHILDREN. 

If  it  is  found  that  the  amount  of  fat  and  total  solids  in  the  milk 
is  too  high  the  diet  of  the  mother  should  be  restricted,  and  exercise 
to  the  point  of  fatigue,  to  divert  the  food  supply  from  the  breasts,  may 
be  advised.  It  may  also  be  necessary  to  give  saline  cathartics.  If 
there  is  an  over-abundant  supply  of  rich  milk,  the  infant  should  be  al- 
lowed to  take  only  the  first  milk  from  each  breast  and  thus  avoid  the 
extra  fat  "strippings"  or  the  last  milk  secreted  which  contains  a  much 
higher  percentage  of  fat  than  the  first  part  of  the  secretion.  If  the 
infant  has  curdy  stools  and  colic,  a  tablespoonful  of  barley  water,  lime- 
water,  or  water  containing  one  grain  sodium  citrate  may  be  given  just 
before  each  nursing. 

If  the  methods  of  management  suggested  above  do  not  overcome 
the  difficulty,  so  that  the  infant  gains  from  four  to  six  ounces  a  week, 
with  good  digestion  and  normal  stools,  it  w^ill  be  necessary  to  resort  to 
mixed  feeding.  Give  a  bottle  every  other  feeding,  using  a  formula  suit- 
able for  a  younger  infant  at  the  beginning,  as  described  on  page  149. 

Examination  of  Breast-milk. — There  are  three  w-ays  of  examining 
breast  milk:  (1)  by  having  an  analysis  made  showing  its  percentage 
composition  expressed  in  proteins,  mineral  matter,  fats,  carbohydrates, 
and  water;  (2)  by  roughly  determining  these  ingredients  by  means  of 
the  amount  of  cream  that  will  rise  on  a  given  quantity  of  milk  and  the 
specific  gravity  of  the  milk;  (3)  by  the  use  of  the  pioscope. 

The  chemical  analysis  of  milk  is  expensive,  and  its  value  is  apt  to 
be  overestimated.  It  takes  several  days  to  get  a  report  from  the 
laboratory  where  it  is  made,  and  laboratories  for  this  purpose  iare  not 
always  available.  The  second  method  of  determining  fats  and 
specific  gravity  takes  twenty-four  hours,  but  can  be  utilized  anywhere. 
A  specimen  of  the  milk  is  drawn  from  the  breast,  care  being  taken  to 
get  all  there  is,  because  the  first  portion  contains  little  fat,  while  the 
last  portion  or  "strippings"  is  very  rich  in  fat.  The  milk  is  mixed 
and  its  specific  gravity  is  taken  with  an  ordinary  urinometer.  Ten 
cubic  centimeters  of  the  milk  are  then  placed  in  a  graduated  ten  c.c. 
tube  or  graduate  and  allowed  to  stand  twenty-four  hours  for  the 
cream  to  rise.  Poor  milk  will  have  a  small  layer  of  cream  and  rich 
milk  a  much  thicker  cream  layer.  The  amount  of  fat  in  the  milk  is 
thus  estimated.  The  specific  gravity  of  normal  human  milk  is  about 
1.031.  If  the  milk  shows  a  layer  of  cream  not  over  one  c.c,  and  has 
this  specific  gravity,  it  may  be  looked  upon  as  normal  milk  as  far  as 
percentage  composition  is  concerned.  If  the  specific  gravity  should  be 
as  low  as  1.028,  with  more  cream,  it  would  indicate  that  the  milk  was 
rich  in  fat,  as  the  fat  being  lighter  than  the  milk  serum  reduces  the 
specific  gravity  of  the  milk. 


BREAST-FEEDING.  105 

This  method  is  widely  used  in  the  dairy  industry  for  calculating 
the  composition  of  cow's  milk,  but  the  fat  is  accurately  determined 
by  the  Babcock  test  (page  171),  which  may  also  be  used  with  human 
milk.  About  half  an  ounce  of  milk  is  required  for  this  test,  but  if 
this  quantity  cannot  be  obtained,  what  is  available  may  be  diluted 
with  water  two  or  three  times  after  the  specific  gravity  has  been 
obtained  and  the  result  multiplied  by  the  number  of  times  the  milk 
was  diluted. 

If  the  specific  gravity  is  above  1.03  and  there  is  little  cream, 
or  fat  shown  by  the  Babcock  test,  the  milk  is  poor  in  fat  and  normal 
in  other  solids,  or  all  of  the  milk  was  not  drawn  from  the  breast  and 
the  portion  containing  the  fat  was  left  behind.  A  second  specimen 
should  be  drawn  and  greater  care  taken  to  get  all  there  is.  The  milk 
should  be  drawn  at  the  regular  nursing  interval  or  milk  extra  rich  in 
fat  will  be  obtained,  for,  as  stated  before,  milk  drawn  at  short  intervals 
is  abnormally  rich  in  fat. 

At  one  time  great  importance  was  laid  upon  the  reaction  of 
breast  milk.  It  was  supposed  always  to  be  alkaline  or  amphoteric 
in  reaction.  At  present  comparatively  little  importance  is  attached 
to  the  reaction  of  breast  milk,  for  the  same  specimen  of  milk  may  be 
found  to  be  acid,  amphoteric,  and  alkaline,  all  depending  upon  how 
the  reaction  is  determined.  Litmus-paper  was  the  substance  used 
to  determine  the  reaction  of  milk,  a  strip  being  dipped  into  the  milk 
and  its  reaction  judged  by  the  change  of  color  of  the  litmus-paper. 
Litmus  and  litmus-paper  vary  a  great  deal  in  sensitiveness,  and  all 
kinds  of  reactions  can  be  obtained  with  milk  by  using  different  lots 
of  litmus-paper.  Phenolphthalein  in  1  per  cent, 
alcoholic  solution  is  now  used  as  the  indicator 
in  testing  the  reaction  of  both  human  and  cow's 
milk,  as  it  is  many  times  more  sensitive  than 
litmus.  Lime-water  is  usually  employed  in 
neutralizing  acidity  in  milk,  and  it  takes  about 
10  per  cent,  to  20  per  cent,  to  make  human 
milk  alkaline  to  phenolphthalein.  With  a 
better  understanding  of  the  chemistry  of  milk  Fig.  32.— Pioscope 
and  the  process  of  its  digestion,  it  is  seen  that  ^^^^^ 

undue  importance  was  placed  upon  its  reaction  and  composition,  and 
simpler  and  better  methods  of  clinically  testing  the  suitability  of 
breast  milk  are  coming  more  into  use. 

Fig.  32  is  an  illustration  of  the  pioscope  which  is  used  for  testing 
breast  milk.  It  consists  of  two  disks,  one  of  hard  rubber  and  the  other 
of  glass,  which  rests  upon  the  rubber  disk.     The  glass  disk  is  divided 


106 


DISEASES  OF  CHILDREN. 


into  sectors  which  are  colored  to  represent  milk  of  different  qualities. 
The  milk  is  drawn  from  the  breast  and  a  few  drops  are  placed  in  a  little 
depression  in  the  rubber  disk.  The  glass  disk  is  then  placed  on  the 
rubber  one  and  the  milk  is  compared  with  the  different  sectors  of  the 
glass  disk.  At  a  glance  one  can  tell  approximately  the  quality  of  the 
milk.  The  apparatus  is  about  one-fourth  of  an  inch  thick  and  can  be 
easily  carried  by  the  physician.  Its  great  advantage  lies  in  the  fact 
that  it  enables  the  physician  to  know  at  once  what  the  conditions  he 
has  to  deal  with  are,  and  it  requires  no  skill  in  using.  The  following 
case  illustrates  its  usefulness.     An  infant  which  was  being  breast  fed 


Fig.  33. — Breast 
pump. 


Fig.  31  —Hoover 
breast  pump. 


and  had  previously  been  doing  well  suddenly  suffered  with  digestive 
disturbance.  The  milk  of  each  breast  was  tested  with  the  pioscope, 
and  it  was  found  that  the  milk  from  one  breast  corresponded  with 
"normal"  on  the  pioscope,  while  that  of  the  other  breast  did  not. 
Directions  were  given  to  nurse  from  the  normal  breast  and  the  infant 
had  no  further  trouble.  The  difference  in  the  milk  was  discernible  by 
the  eye.  If  the  milk  of  both  breasts  had  been  mixed  and  analyzed, 
or  its  composition  estimated  from  its  specific  gravity  and  cream  layer, 
the  fact  that  the  milk  of  one  breast  was  different  from  that  of  the 
other  in  all  probability  would  not  have  been  known,  and  the  treatment 
might  have  been  to  stop  breast-feeding  and  try  artificial  feeding,  which 
as  it  proved  was  unnecessary.  » 


BREAST-FEEDING.  107 

Nursing  not  Possible. — When  the  nipples  are  fissured  it  is  impos- 
sible for  the  infant  to  nurse,  and  the  milk  should  be  drawn  with  a 
breast  pump,  two  forms  of  which  are  shown  in  Figs.  33,  34.  The 
Hoover  breast  pump  (Fig.  34)  will  be  found  convenient  and  easy 
to  use.  Heating  an  empty  bottle  and  placing  the  neck  over  the  nipple 
will  sometimes  prove  satisfactory  in  collecting  milk.  The  milk  may  be 
fed  through  a  medicine  dropper  or  from  a  small  nursing  bottle.  Pumps 
and  bottle  should  be  kept  scrupulously  clean. 

When  there  is  but  a  slight  fissure  or  abrasion  which  causes  pain 
to  the  mother,  a  nipple  shield  (Fig.  35)  may  be  used.  It  is  best 
to  fill  it  with  warm  water  so  that  the  infants  will  not  have  to  exhaust 
the  air  it  contains  before  obtaining  any  fluid.     It  ^^ 

is  also  well  to  massage  the  breasts  to  aid  in  secur-  fl^B 

ing   the   milk.      The   nipples   should   be   carefully  ^^V 

washed   with  a  solution  of  boric   acid  and  dried  ^^Km^ 

Contraindications     for    Nursing. — When     the         f''"'^^^ 
mother  is  anemic  and  is  losing  weight  and  shows  k-j^^^B 

signs  of  exhaustion,  even  after  tonic  treatment  has    ^^mJJhH^^ 
been  employed;  or  when  she  is  nervous  and  excit-  ^^^  ^^Sfc 

able  to  such  an  extent  that  her  milk  continually  ^'***— .._..— ««*^ 
disagrees  with  the  infant,  breast-feeding  should  be     ^^^  "^hTrf*^^^^^ 
discontinued.      If  when  menstruation   is   resumed 
the  milk  disagrees,  artificial  feeding  may  be  employed  temporarily, 
and  after  the  period  has  passed  breast-feeding  may  be  commenced. 
In  the  meantime  the  breast  should  be  emptied  with  a  breast  pump 
at  regular  intervals  to  keep  up  the  secretion.     If  the  milk  disagrees 
but  slightly  it  may  not  be  necessary  to  feed  artificially.  i 

If  pregnancy  occurs  it  may  be  necessary  to  employ  substitute 
feedings,  but  in  the  middle  of  a  hot  summer  it  will  be  better  to  con- 
tinue the  breast-feeding,  if  it  is  not  too  much  of  a  strain  on  the  mother, 
than  to  risk  the  dangers  of  commencing  artificial  feeding  in  hot 
weather.  Mothers  affected  with  tuberculosis  should  under  no  cir- 
cumstances be  permitted  to  nurse  their  infants.  Diseases  such  as 
typhoid,  pneumonia,  and  septicemia  in  which  there  is  much  pyrexia 
and  prostration  also  are  contraindications  to  nursing.  ^ 

Weaning  and  Mixed  Feeding. — Whenever  the  mother's  milk  fails 
in  quantity  or  quality,  it  becomes  necessary  to  commence  substitute 
feeding  to  make  up  the  deficiency.  It  is  a  good  plan  to  have  one  bottle 
a  day  given  to  a  nursing  infant  about  the  third  month  so  it  shall  be 
trained  to  its  use  and  the  mother  trained  in  the  preparation  of  food. 
This  will  be  much  appreciated  in  cases  where  sudden  weaning  becomes 


108  DISEASES  OF  CHILDREN. 

necessary.  The  substitute  feeding  may  alternate  with  breast-feedings, 
and  as  the  breast  secretion  fails  the  number  of  bottles  given  may  be 
increased  one  at  a  time.  In  this  way  the  transition  is  gradual  and 
digestive  disturbances  are  avoided.  During  the  first  few  weeks  of 
life,  when  the  nursing  mother  has  little  milk,  a  small  amount  may  be 
given  from  the  bottle  immediately  after  nursing  if  the  infant  gets  too 
little  from  the  breast. 


Fig.  36. — Preferable  type  of  breasts  for  wet-nursing. 

Whenever  sudden  weaning  becomes  necessary  a  wet-nurse  should 
be  employed  if  possible,  as  no  substitute  feeding  can  compare  with 
good  wet-nursing. 

Selection  of  a  Wet-nurse. — In  selecting  a  wet-nurse,  we  must 
consider  her  age,  her  general  health  and  development,  her  probable 
nervous  status,  and  the  age  and  health  of  her  infant.  The  preferable 
age  for  the  nurse  is  between  twenty  and  thirty  years,  and  multiparas 


BREAST-FEEDING.  109 

are  apt  to  do  better  than  primiparse  on  account  of  having  had  charge 
of  the  suckling  and  general  care  of  infants.  A  careful  physical 
examination  of  the  applicant  should  be  made  by  the  physician. 
Constitutional  taints,  especially  syphilis  and  tuberculosis,  must  be 
excluded  by  a  painstaking  history  and  thorough  examination  of  the 
mouth,  lymph-glands,  skin,  and  other  parts  likely  to  show  evidences 
of  infection.  If  any  vaginal  discharge  is  present,  it  must  be  ex- 
amined for  gonococci.  The  best  breasts  for  satisfactory  suckling 
are  not  the  large,  firm  ones,  but  rather  the  more  flabby  and  pendu- 
lous kind,  as  shown  in  Fig.  36.  The  nipple  must  be  of  good  form 
and  size  and  sufficiently  protuberent  for  easy  grasping  by  the  infant, 
and  free  from  fissures  and  abrasions.  A  woman  of  quiet,  phleg- 
matic temperament,  in  good  health,  is  to  be  preferred,  as  nervous 
instability  has  a  quick  effect  on  the  composition  of  the  milk.  A 
woman  whose  infant  is  under  six  months  can  usually  suckle  a  new- 
born baby,  but  a  less  disparity  between  the  ages  of  the  infants  is 
desirable  if  it  can  be  attained.  A  careful  examination  of  the  nurse's 
infant  must  be  made  to  exclude  any  constitutional  disease,  especially 
syphilis.  Such  examination  will  also  show  how  well  the  infant  has 
thriven  upon  its  mother's  milk.  The  diet  of  the  wet-nurse,  when  se- 
lected, should  be  as  nearly  as  possible  that  to  which  she  has  been  accus- 
tomed, avoiding  a  too  great  variety  and  quantity  of  food.  If  she  is 
furnished  a  diet  richer  and  more  abundant  than  she  is  accustomed 
to,  she  will  in  all  probability  overeat  and  bring  on  either  defective 
digestion  or  excretion,  which  will  promptly  disorder  the  digestion  of  the 
infant.  Regular  outdoor  exercise  must  also  be  insisted  upon.  Several 
nurses  will  sometimes  have  to  be  tried  before  a  breast  that  agrees  with 
the  baby  is  found. 


CHAPTER  XIII. 
THE  PRINCIPLES  OF  SUBSTITUTE  FEEDING. 

Difficulties  Encountered. — In  attempting  to  feed  infants  artificially, 
one  of  the  first  impressions  received  is  that  the  whole  subject  is  chaotic. 
Methods  that  give  brilliant  results  in  some  instances  totally  fail  in 
other  cases  apparently  the  same.  One  infant  will  thrive  on  a  quantity 
of  food  that  is  insufficient  for  another  of  the  same  age;  another  may 
gain  in  weight  rapidly  and  still  not  be  rugged  and  well-developed. 
The  parents  may  be  poor,  ignorant,  or  careless,  and  great  difficulty  may 
be  experienced  in  getting  a  supply  of  suitable  food,  or  in  having  the 
food  prepared  and  administered  properly.  Learning  the  formulas  of 
a  few  food  mixtures  will  never  make  a  good  or  successful  infant  feeder. 
What  is  required  is  a  clear  conception  of  what  are  the  essential  prin- 
ciples involved  in  artificial  infant-feeding  in  health, and  disease,  and  a 
working  knowledge  of  how  to  prepare  food  so  that  these  principles 
may  be  complied  with  under  different  conditions. 

Principles  that  Apply  to  all  Infants. — All  infants  require  a  certain 
quantity  of  proteins  and  mineral  matter  to  replace  normal  metabolic 
waste,  and  enough  fats  and  carbohydrates  to  supply  the  energy  needed 
to  carry  on  the  processes  of  life.  A  food  that  supplies  exactly  these 
quantities  of  the  food  elements  is  called  a  maintenance  ration,  and  on 
such  a  food  the  infant  would  neither  gain  nor  lose.  Oftentimes  in 
cases  of  illness  it  becomes  necessary  to  put  infants  on  such  food,  and 
the  parents  may  feel  the  infants  are  being  starved,  but  they  are  not  on 
a  starvation  diet  by  any  means;  growth  is  suspended  temporarily,  but 
the  infant  is  holding  its  own. 

After  the  portion  of  the  food  needed  for  maintenance  has  been  ap- 
propriated, what  remains,  if  any,  may  be  utilized  for  growth  or  for 
causing  gain  in  weight  which  does  not  necessarily  mean  that  the  infant 
is  really  growing.  Growth  consists  in  an  increase  in  number  of  the 
cells  of  the  various  tissues,  and  as  these  are  composed  principally  of 
proteins  and  water  the  food  must  contain  a  greater  quantity  of 
proteins  than  is  required  to  replace  waste,  if  growth  is  to  be  made 
possible,  for  cells  cannot  be  formed  from  fats  and  carbohydrates.  A 
rapid  gain  in  weight  may  result  if  the  food  given  contains  only  a  little 
more   protein  than  is  necessary  to  replace  waste,  but  considerable 

110 


THE  PRINCIPLES  OF  SUBSTITUTE  FEEDING.  Ill 

fat  and  carbohydrates,  as  the  excess  of  these  ingredients  is  con- 
verted into  body  fat  which  causes  increase  in  weight.  To  those  not 
familiar  with  the  principles  of  infant-feeding  this  gain  in  weight  is 
strong  evidence  that  the  food  is  suitable  for  the  infant,  but  not  so 
much  importance  is  attached  to  mere  gain  in  weight  as  formerly.  If 
the  food  is  known  to  contain  a  liberal  supply  of  proteins,  and  gain  in 
weight  follows  its  use,  it  is  considered  that  the  gain  in  weight  is  caused 
by  true  growth,  as  it  is  characteristic  of  young  animals  of  all  kinds  to 
greedily  assimilate  and  convert  into  tissues  the  proteins  that  the  food 
contains  in  excess  of  that  needed  to  replace  waste,  within  reasonable 
limits.     Proper  growth  hinges  on  the  proteins  of  the  food. 

If  the  food  contains  a  relatively  large  proportion  of  proteins 
with  a  too  small  proportion  of  fats  and  carbohydrates  the  proteins 
will  be  used  to  sujDply  energy  which  could  just  as  well  be  furnished 
by  fats  and  carbohydrates,  and  growth  will  not  take  place.  If  the 
quantity  of  fats  and  carbohydrates  is  increased  and  the  amount  of 
proteins  decreased  somewhat  the  infant  will  be  able  to  make  a  satis- 
factory growth,  therefore  it  is  important  to  have  the  food  elements 
present  in  the  food  in  certain  relative  proportions  if  best  results  are 
to  be  obtained. 

It  is  possible  to  profoundly  alter  the  character  of  the  body  by 
modifications  of  the  diet  during  the  early  growing  period.  Much 
scientific  work  has  been  done  along  this  line  at  the  Agricultural 
Experiment  Stations  of  the  various  States  in  the  efforts  to  learn  the 
principles  involved  in  the  production  of  meat  for  market,  and  how  to 
select  food  so  as  to  produce  the  most  rugged  animals.  It  was  found 
that  a  liberal  supply  of  protein  in  the  early  stages  of  growth  produced 
larger  animals,  made  their  vital  organs  larger,  gave  them  more  blood, 
stronger  bones,  and  about  one-third  more  muscle  than  food  poor  in 
proteins,  but  rich  in  fats  and  carbohydrates. 

The  essentials  of  artificial  infant  feeding  are:  a  liberal  supply  of 
proteins  and  mineral  matter  for  the  construction  of  additional  tissue, 
which  means  growth;  a  sufficient  supply  of  fats  and  carbohydrates  to 
furnish  energy,  and  all  in  forms  that  can  be  not  only  digested  by  the 
infant,  but  which  permit  the  development  of  vigorous  digestive 
organs.  A  strong  digestive  apparatus  is  of  great  importance  in  after- 
life, and  by  proper  selection  of  food  in  infancy  the  foundation  for  good 
digestion  later  on  can  be  laid. 

Many  Forms  of  Proteins,  Fats,  and  Carbohydrates  Used  in  Feeding 
Infants. — Proteins  for  infants  are  obtained  in  cow's  or  goat's  milk, 
from  cereals,  and  from  eggs,  and  in  a  few  instances  in  the  form  of  meat 
broths  and  meat  juice.     The  cereals  should  be  looked  upon  as  vege- 


112  •  DISEASES  OF  CHILDREN. 

table  eggs,  as  they  are  composed  of  the  embryo  plant  and  enough  food 
to  nourish  its  protoplasm  with  proteins  and  carbohydrates  until  its 
organs  for  securing  food  are  developed.  Mineral  matter  which  is  a 
mixture  of  many  salts  is  obtained  in  milk  and  the  cereals,  in  com- 
bination with  the  proteins  presumably,  for  it  is  never  supplied  in  a 
separate  state.  Fats  are  taken  in  the  form  of  milk  or  cream  almost 
exclusively.  Carbohydrates  are  utilized  in  the  form  of  milk-sugar, 
granulated  sugar,  maltose  and  dextrin  derived  from  starch,  and 
cooked  starch. 


CHAPTER  XIV. 
MATERIALS  USED  IN  SUBSTITUTE  FEEDING. 

Cow's    Milk. 

General  Composition. — Chemical  analysis  shows  the  milk  of  all 
cows  to  be  composed  of  proteins,  mineral  matter,  fats,  carbohydrates, 
and  water,  but  the  proportions  of  these  ingredients  are  not  the  same 
in  all  specimens  of  milk  from  the  same  cow  or  from  the  cows  of  dif- 
ferent breeds.  The  composition  of  milk  depends  largely  on  the  breed 
of  cow,  the  individual  peculiarities  of  each  cow,  and  the  time  and 
manner  of  milking. 

One  Cow's  Milk. — It  was  formerly  believed  that  the  milk  of  one 
cow  was  preferable  to  the  mixed  milk  of  a  herd  of  cows  for  use  in  infant- 
feeding,  but  as  improved  and  more  sanitary  methods  of  handling  herd 
milk  have  done  away  with  much  of  the  contamination  which  brought 
such  milk  into  disrepute,  it  is  now  much  better  to  use  the  mixed  milk 
of  a  large  number  of  cows,  especially  as  it  is  more  uniform  in 
composition  and  less  liable  to  sudden  fluctuations  and  changes  of 
properties. 

The  range  of  composition  of  the  milk  of  single  cows  has  been 
found  to  be  from  2.25  per  cent,  to  9  per  cent,  of  fat,  and  2.19  per  cent, 
to  8.56  per  cent,  proteins  (Van  Slyke),  while  in  mixed  herd  milk 
there  is  seldom  much  of  a  range  of  variation,  the  fats  running  almost 
never  below  3  per  cent,  and  very  seldom  over  5  per  cent.,  except  in 
the  milk  of  high-bred  Guernsey  and  Jersey  cows;  while  the  proteins 
will  almost  always  run  between  3  per  cent,  and  3.5  per  cent. 

If  a  cow  is  affected  with  tuberculosis  the  danger  of  infecting  the 
infant  is  much  greater  than  if  her  milk  is  diluted  by  the  milk  of  other 
cows  which  are  free  from  tuberculous  infection.  Again,  the  com- 
position and  properties  of  a  cow's  milk  are  seriously  affected  by  fright, 
worry,  teasing  by  a  dog,  or  the  annoyance  of  flies.  The  milk  of  a 
frightened  cow  has  been  known  to  kill  her  calf,  so  the  use  of  one  cow's 
milk  is  attended  with  greater  risks  than  the  milk  of  a  herd  of  healthy 
cows  that  has  been  properly  handled  as  it  is  not  likely  that  all  of  the 
cows  would  be  subjected  to  the  same  abnormal  conditions. 

Influence  of  Breed  on  Composition  of  Milk. — The  milk  of  different 
breeds  of  cows  shows  marked  differences  of  composition  and  no 
8  113 


114  DISEASES  OF  CHILDREN. 

amount  of  effort  will  make  the  cows  of  one  breed  give  milk  of  the  same 
character  as  the  cows  of  another  breed.  Holstein  cows  wuU  give  milk 
containing  about  3  per  cent,  fat,  2.80  per  cent,  proteins,  and  4  per  cent, 
carbohydrates,  while  Jersey  cows  will  give  milk  containing  as  high  as 
5.5  per  cent,  fat,  3.60  per  cent,  proteins,  and  5  per  cent,  carbohydrates. 
Other  breeds  give  milks  which  fall  between  these  two  extremes,  but 
it  is  seldom  that  milk  of  pure-bred  cows  is  offered  for  sale  unless  it  is 
from  the  dairy  of  some  ''gentleman  farmer"  who  is  a  cattle  fancier. 

Bacteriology  of  Milk. — Milk  as  secreted  by  a  healthy  udder  is 
practically  sterile,  but  just  inside  the  teat  is  a  "  milk  cistern"  to  which 
bacteria  from  outside  find  access.  For  this  reason  the  first  three  or 
four  jets  from  each  teat  should  be  discarded  and  then  the  milk  will 
be  quite  free  from  bacteria  if  received  under  proper  conditions  into 
sterile  pails.  But  owing  to  the  small  profit  or  possibly  no  profit  at 
all  that  comes  to  the  milk  producer,  as  most  milk  is  sold  at  about  the 
cost  of  production,  he  cannot  take  proper  care  of  his  cows  or  the 
utensils  employed,  and  the  milk  becomes  highly  infected  at  times 
with  all  kinds  of  bacteria,  some  of  them  pathogenic.  A  visit  to  one 
of  the  barns  in  which  cows  were  kept  for  the  production  of  milk  for 
market  a  few  years  ago  would  have  shown  a  dark,  poorly  ventilated 
building,  the  beams  covered  with  dust  and  cobwebs,  the  bodies  of  the 
cows  plastered  over  with  manure,  and  piles  of  loose  hay  and  manure 
lying  near  the  cows  while  the  milking  was  being  done.  Milk  from 
such  dairies  would  contain  hundreds  of  millions  of  bacteria  to  the 
cubic  centimeter,  but  fortunately  most  of  these  bacteria  were  sapro- 
phytes, and  the  harm  they  did  was  chiefly  in  souring  the  milk  by 
converting  its  sugar  into  lactic  acid  or  decomposing  the  proteins.  In 
hot  weather  the  heat  would  favor  development  of  new  bacteria  and 
the  milk  would  not  keep.  This  led  to  a  demand  for  sterilization  or 
pasteurization,  but  it  has  since  been  found  that  it  is  much  better  to 
produce  milk  under  sanitary  conditions  and  thus  keep  down  the 
number  of  bacteria  than  to  kill  them  .by  heat  after  they  have  been 
allowed  to  get  into  the  milk  and  attack  it. 

Another  thing  that  would  have  been  noticed  at  this  dairy,  possibly, 
is  that  the  milkers  did  not  wash  their  hands  or  wear  clean  clothes,  and 
that  the  water  used  in  washing  milk  pails  and  cans  came  from  a  well 
close  to  a  water-closet.  If  there  was  an  infectious  disease,  such  as 
scarlet  fever  or  typhoid  fever  in  the  family  of  any  of  those  who  handled 
the  milk,  the  opportunity  for  infecting  the  milk  was  present,  and 
there  are  many  recorded  instances  where  epidemics  of  typhoid  fever 
particularly  have  been  caused  by  milk  infected  by  those  handling  the 
milk  or  by  water  used  in  washing  utensils. 


MATERIALS  USED  IN  SUBSTITUTE  FEEDING.  115 

Fortunately,  this  state  of  affairs  is  not  as  common  as  formerl}^ 
and  the  physician  to-day  does  not  have  the  problems  to  contend  with 
in  obtaining  a  good  supply  of  milk  that  the  physician  of  ten  years  ago 
had  to  deal  with.  The  principles  involved  in  the  production  of  whole- 
some milk  are  now  well  understood,  and  are  being  applied  more  and 
more  even  in  remote  parts  of  the  country,  and  good  milk  suitable  for 
feeding  infants  can  be  produced  anywhere  b}'  the  exercise  of  care  and 
cleanliness. 

Production  of  Sanitary  Milk. — All  that  is  needed  to  produce  milk 
suitable  for  feeding  infants  are  cows  that  are  free  from  tuberculosis 
or  other  disease,  a  stable  that  can  be  kept  clean — an  ordinary  barn  will 
do — and  careful  attention  to  keeping  the  cows  and  utensils  clean. 
The  cows  are  to  be  cleaned  daily  and  kept  as  sleek  and  clean  as 
horses.  The  hair  on  the  udder  is  to  be  kept  cut  short  and  the  udder 
and  belly  are  to  be  wiped  off  with  a  damp  cloth  just  before  milking. 
No  loose  hay  or  manure  are  to  be  left  in  the  stable  when  milking  is 
going  on,  as  dust  from  them  carries  bacteria  with  it  into  the  milk. 
All  utensils  are  to  be  washed  with  boiling  water,  and  steamed  if 
possible.  The  milker  should  w^ear  clean  clothes,  and  his  hands  should 
be  washed  with  soap  and  water  just  before  milking.  The  first  few 
streams  of  milk  from  each  teat  should  be  thrown  away,  not  into  the 
milk  pail,  but  into  the  manure  gutter,  and  the  milking  should  then 
proceed  into  a  small  mouth  pail.  The  milk  should  then  be  strained 
through  a  sterile  cloth  and  cooled  and  iced  and  kept  iced  until  ready 
for  consumption. 

The  bacterial  condition  of  milk  is  of  as  much  importance  as  its 
chemical  composition  and  should  never  be  left  out  of  consideration. 
It  is  well  also  to  remember  that  methods  of  milk  production  in  America 
and  Europe  are  totally  different,  and  that  European  literature  on  this 
subject  does  not  always  apply  to  American  conditions. 

Market  Milk. — From  a  commercial  standpoint  milk  may  be 
divided  into  three  grades:  (1)  "Grocery  milk, "such  as  is  sold  at  very 
low  prices  in  city  grocery  stores,  especially  in  the  tenement  districts, 
and  dipped  out  of  cans  into  the  family  pitcher;  (2)  bottled  milk,  such 
as  is  delivered  to  families  in  glass  bottles  in  the  more  well-to-do 
sections;  (3)  sanitary,  inspected,  or  certified  milk,  which  is  also  sold 
in  bottles. 

Grocery  milk  is  produced  at  as  low  a  cost  as  possible  and  con- 
tains enormous  numbers  of  bacteria,  as  no  more  care  is  taken  in  its 
production  than  the  health  authorities  insist  upon.  It  is  a  poor  food 
for  infants,  especially  in  hot  weather,  when  it  may  be  positively 
dangerous. 


116  DISEASES  OF  CHILDREN. 

Bottled  milk  is  generally  produced  under  much  better  conditions 
than  grocery  milk  and  sells  for  about  double  the  price  of  the  grocery 
milk.  It  forms  a  satisfactory  milk  for  infant  feeding  in  a  large  number 
of  instances. 

Sanitary,  inspected,  or  certified  milk  is  produced  under  the  super- 
vision of  a  commission  of  physicians,  usually  appointed  by  a  local 
medical  society.  Such  commissions  furnish  standards  of  cleanliness 
and  bacterial  count  which  are  to  be  complied  with.  Then  if  the  milk 
when  taken  at  random  from  the  milkman's  delivery  wagon  comes  up 
to  the  standard,  he  is  furnished  with  a  label  certifying  that  the  milk  is 
of  the  required  quality,  or  "certified  milk,"  as  it  is  often  called.  The 
standards  fixed  by  "milk  commissions"  in  different  cities  are  not  all 
alike.  In  Philadelphia,  for  instance,  the  number  of  bacteria  per  cubic 
centimeter  must  not  exceed  ten  thousand,  while  in  New  York  the 
maximum  number  must  be  not  over  thirty  thousand  per  cubic  centi- 
meter. Certified  milk  is  the  safest  and  best  milk  obtainable  for  use  in 
infant  feeding,  and  can  now  be  had  in  most  large  cities  and  in  some 
small  ones.  There  is  no  reason  why  it  should  not  be  obtainable  any- 
where. Any  progressive  dairyman  or  farmer  can  produce  it.  The 
price  of  this  milk  is  50  to  100  per  cent,  higher  than  that  of  ordinary 
bottled  milk. 

It  is  important  that  the  certification  be  done  by  some  competent 
medical  authority  and  no  milkman  should  be  allowed  to  do  his  own 
certifying. 

Pasteurized  and  Sterilized  Milk. — By  heating  the  milk  to  about 
160°  F.  for  about  twenty  minutes  the  great  majority  of  bacteria  pres- 
ent are  destroyed.  Such  treatment  of  milk  is  called  pasteurization. 
If  the  milk  is  heated  to  212°  F.  it  is  said  to  be  sterilized,  as  all  of  the 
bacteria  are  destroyed.  In  both  of  these  processes  the  bacterial  spores 
survive,  and  if  the  milk  is  not  kept  below  50°  F.  they  will  germinate, 
and  soon  the  milk  will  contain  as  many  bacteria  as  it  did  originally, 
but  the  type  or^kind  of  bacteria  will  not  be  the  same.  Bacteria  that 
convert  the  sugar  of  milk  into  acid  and  cause  souring  are  the  pre- 
dominating kinds  in  fresh  milk  and  the  acid  they  produce  retards 
the  growth  of  other  types,  until,  when  milk  is  nearly  soured,  95  per 
cent,  of  all  the  bacteria  present  are  acid  producers.  Heating  the 
milk  to  above  150°  F.  destroys  the  acid  bacteria  and  leaves  a  free 
field  for  bacteria  that  attack  proteins.  Therefore  pasteurized  or 
sterilized  milk  does  not  readily  sour,  but  its  proteins  are  often  partially 
decomposed  by  bacteria  produced  from  spores  which  escaped  de- 
struction, and  such  milk  may  cause  considerable  digestive  disturbance. 
Pasteurization  or  sterilization  may  be  used  to  take  the  place  of  clean- 


MATERIALS  USED  IN  SUBSTITUTE  FEEDING.  117 

liness  in  producing  milk,  but  it  is  not  to  be  advocated  for  this  purpose. 
If  the  milk  is  suspected  of  conveying  pathogenic  bacteria,  then  it  should 
be  pasteurized,  but  this  should  be  done  if  possible  in  the  home  when 
the  infant's  food  is  prepared,  so  that  there  shall  be  no  opportunity 
for  contamination  between  the  time  the  milk  is  pasteurized  and  the 
infant  receives  its  food,  for  pasteurized  milk  is  just  as  liable  to  be  un- 
healthful  as  fresh  milk  if  it  is  not  protected  from  reinfection.  Ster- 
ilized milk  is  not  used  to  any  great  extent  because  it  has  a  cooked  taste. 
Pasteurized  milk  tastes  very  much  as  fresh  milk  does,  although  a  differ- 
ence is  discernible.  Heating  milk  in  some  way  alters  it  so  that  it  is 
not  solidified  by  rennin  as  quickly  as  fresh  milk,  and  this  property  is 
often  taken  advantage  of  in  prepairing  food  for  infants  in  whose 
stomachs  fresh  milk  solidifies  too  rapidly.  Heating  the  food  may 
make  it  digest  satisfactorily. 

Composition  of  Market  Milk. — Nearly  all  of  the  States  have  laws 
regarding  the  composition  of  milk  and  cream.  Most  of  them  require 
the  milk  to  contain  12  per  cent,  of  total  solids,  of  which  at  least  one- 
fourth  must  be  fat.  A  few  States  require  the  milk  to  contain  3.5  per 
cent.  fat.  and  solids  not  fat  9  per  cent,  or  slightly  more. 

Since  the  introduction  of  bottled  milk  the  public  has  become  edu- 
cated to  look  for  a  layer  of  cream  in  the  necks  of  the  milk  bottles. 
Milk  containing  but  3  per  cent,  of  fat  will  not  produce  a  satisfactory 
layer  of  cream,  so  either  cream  is  added  to  milk  containing  but  3  per 
cent,  fat,  or  the  cream  is  allowed  to  rise  on  such  milk,  and  a  portion 
of  the  milk  under  the  cream  is  drawn  off  thus  increasing  the  percentage 
of  fat  in  what  remains.  Milk  for  the  general  bottled  trade  will  contain 
between  3.5  per  cent,  and  4  per  cent,  of  fat,  about  3.20  per  cent, 
proteins,  and  5  per  cent,  sugar  and.  mineral  matter.  Some  milk 
dealers  with  poor  facilities  will  bottle  3  per  cent,  fat  milk,  but  it 
will  not  pass  with  most  purchasers  of  bottled  milk.  Bottled  milk 
from  fancy  Jersey  cattle  will  contain  from  4.5  per  cent,  to  5.5  per  cent, 
fat,  3.5  per  cent,  proteins,  and  5  per  cent,  sugar  and  mineral  matter. 
Certified  milk  generally  contains  4  to  5  per  cent,  of  fat,  with  the  other 
ingredients  about  the  same  as  in  good  bottled  milk. 

Cream. — There  are  two  kinds  of  cream  sold  by  milk  dealers: 
(1)  Gravity  cream,  or  that  which  rises  naturally  if  the  milk  is  allowed 
to  stand;  (2)  centrifugal  cream,  or  that  which  is  separated  by  passing 
the  milk  through  a  centrifuge  running  at  a  high  rate  of  speed.  The 
percentage  of  fat  in  cream  varies,  running  all  the  way  from  16  per  cent, 
up  to  40  per  cent.  Some  gravity  cream  may  run  as  low  as  16  per  cent, 
and  as  high  as  25  per  cent.  Centrifugal  cream  can  be  made  of  any 
desired  percentage  of  fat  by  adjusting  the  centrifuge.     There  are 


118 


DISEASES  OF  CHILDREN. 


marked  physical  differences  between  gravity  cream  and  centrifugal 
creams.  Gravity  cream  will  "whip"  much  better  than  centrifugal 
cream,  and  for  some  purposes  in  catering  centrifugal  cream  cannot  be 
employed.     Centrifugal  cream  is  much  thinner  than  gravity  cream 


^f...    ,,  ■■■y:"Mi^ apt 


Fig.  37. — Microscopic  appearance  of  normal  milk      {Babcock  and  Russell.) 
Fat  globules  in  clusters. 


Fig.  38. — Microscopic   appearance   of  centrifuged,   or  heated   milk. 
(Babcock  and  Russell.)     Fat  globules  not  in  clusters. 


of  the  same  composition.  Heating  or  pasteurizing  milk  or  cream 
produces  much  the  same  effect  as  centrifuging,  and  to  overcome  the 
effect  of  these  processes  there  has  been  invented  a  method  of  restor- 
ing the  ''body"  to  such  milk  or  cream,  which  consists  in  adding  a 


MATERIALS  USED  IN  SUBSTITUTE  FEEDING. 


119 


combination  of  calcium  hydrate  with  cane-sugar,  called  syrup  of  lime 
or  "viscogen."  This  substance  will  cause  cream  or  milk  to  thicken 
perceptibly,  and  is  sometimes  used  to  make  poor  cream  appear  like 
richer  cream.  Figs.  37,  38  show  the  microscopic  appearance  of  normal 
milk  and  milk  that  has  been  centrifuged  or  heated. 

Condensed  Milk. — ^There  are  on 
the  market,  and  widely  used,  a  large 
number  of  brands  of  condensed  milk. 
These  are  made  by  evaporating  milk 
in  vacuum  pans,  at  a  low  tempera- 
ture, after  it  has  been  brought  near 
the  boiling-point.  If  it  is  to  be  sold 
in  the  fresh  state  it  is  then  run  into 
cans  and  shipped  to  market.  Other- 
wise, granulated  sugar  is  added  and 
the  milk  is  then  put  into  small  cans 
and  hermetically  sealed.  Such  milk 
is  known  as  sweetened  condensed 
milk.  It  is  a  one-sided  diet  contain- 
ing an  excess  of  carbohydrates.  It 
will  make  children  very  fat  because 
they  change  its  excess  of  sugar  into 
body  fat,  but  when  it  is  diluted  so 
they  can  digest  it  the  percentage  of 
proteins  or  blood  and  muscle-forming 
portion  of  the  food  is  not  much  more 
than  half  that  of  mother's  milk,  and 
of  course  the  infant  cannot  grow  prop- 
erly on  it.  There  is  also  a  great  de- 
ficiency in  fat. 

Evaporated  Milk. — There  is  also 
sold  in  cans  what  used  to  be  called 
"evaporated  cream"  but  which 
since  the  passage  of  the  "Pure  Food  and  Drugs  Act"  in  1906  is 
called  by  its  true  name  "evaporated  milk."  This  is  condensed  milk 
which  has  been  canned  without  the  addition  of  sugar.  It  has  a 
creamy  consistency  and  when  diluted  with  water  is  very  much  like 
sterilized  milk.  It  does  not  sour  readily,  but  is  liable  to  putrefaction, 
and  for  this  reason  is  put  up  in  small  cans  that  shall  be  used  up  soon 
after  opening.  It  will  not  keep  when  opened  as  will  the  regular 
condensed  milk. 


Fig.  39.— Obesity  with  lack  of 
proper  musculature,  resulting  from 
high  carbohydrates  and  low  protein. 


120  DISEASES  OF  CHILDREN. 

Cereals. 

The  various  cereals  play  an  important  part  in  artificial  infant- 
feeding,  and  when  used  intelligently  are  of  greatest  service.  In 
feeding  sick  infants  and  for  tiding  over  a  period  when  milk  is  not 
tolerated,  the  cereals  and  products  derived  from  them  are  the  main 
reliance.  But  it  should  also  be  remembered  that  if  used  injudiciously 
they  may  cause  considerable  disturbance. 

General  Properties  of  Cereals. — The  cereals  are  essentially  vege- 
table eggs.  That  is,  they  are  composed  of  the  plant  germ  and 
enough  food  to  nourish  this  germ  until  it  has  developed  organs  for 

securing  food  from  the  soil  and  air. 
All  cereals  are  composed  of  fats,  car- 
bohydrates, proteins,  and  mineral 
matter  in  different  proportions.  The 
amount  of  fat  in  wheat  flour  is  about 
1  per  cent.,  while  the  quantity  in  oat- 
meal is  about  9  per  cent.  Barley 
flour  may  contain  as  high  as  3  per 
cent,  fat,  while  pearl  barley  will  con- 

„      .^     ^    ,  •     /^     .  ,        tain   as   little   as   0.7   per    cent.    fat. 

Fig.  40. — Barley  grain.  (Gooda/e.)     t^         • 
c,  Protein  layer;  d,  starchy  portion.    Protems  vary  m  much  the  same  way. 

Barley  flour  may  contain  as  high  as 
13  per  cent,  and  as  low  as  7  per  cent,  proteins.  These  differences 
are  largely  due  to  the  methods  of  preparing  the  cereals  for  use. 
Fig.  40  is  an  illustration  of  a  cross  section  of  a  cereal  in  which 
it  will  be  noticed  that  the  proteins  are  found  in  the  outer  layers  of 
the  grain.  In  making  pearl  barley  the  outer  layers  are  ground  off, 
leaving  the  interior  portion  which  contains  a  relatively  high  pro- 
portion of  carbohydrates  or  starch.  Accordingly,  a  sample  of  barley 
may  contain  13  per  cent,  proteins  and  74  per  cent,  carbohydrates, 
and  after  it  has  been  "pearled"  it  will  contain  7  per  cent,  proteins  and 
77  per  cent,  carbohydrates.  The  proteins  of  barley  make  an  exceed- 
ingly sticky  dough  when  the  flour  is  mixed  with  water,  and  for  this 
reason  it  is  desirable  to  remove  a  portion  of  the  protein  for  certain 
purposes  in  cooking  and  some  flour  is  made  from  barley  from  which 
the  protein  layer  has  been  removed.  Such  flour  stirs  into  water 
very  easily  and  for  cooking  purposes  is  very  convenient.  From  a 
nutritive  standpoint  such  flour  is  not  the  best,  as  in  infant-feeding 
particularly,  the  main  object  is  to  give  as  much  proteins  as  can  be 
utilized,  and  cereals  containing  the  full  quantity  of  protein  are  to  be 
preferred. 


MATERIALS  USED  IX  SUBSTITUTE  FEEDING.  121 

Carbohydrates  of  Cereals. — The  skeleton  and  tissues  of  plants  are 
composed  of  carbohydrates,  while  in  animals  the  tissues  are  mostly 
proteins.  Naturally,  then,  the  cereals  are  composed  largely  of  car- 
bohydrates, the  proteins  which  are  only  necessary  for  the  formation 
of  new  protoplasm  being  present  in  smaller  amounts.  The  carbo- 
hydrates may  be  in  a  number  of  forms,  and  the  plant  and  its  germ  has 
the  power  to  change  one  form  into  another  as  is  needed.  For  for- 
mation of  plant  tissues  they  may  be  changed  into  cellulose,  of  which 
cotton  is  a  good  example.  For  storage  of  a  reserve  supply  they  may  be 
changed  into  starch  or  inulin.  When  the  reserve  or  starch  is  drawn 
upon,  the  plant  secretes  enz3'mes  which  change  the  starch  into  a 
soluble  form.  The  starch  first  becomes  soluble,  it  is  then  changed 
into  dextrin  and  finally  into  maltose.  These  changes  can  readily  be 
brought  about  in  preparing  food  for  infants,  and  this  fact  is  of  impor- 
tance, for  oftentimes  carbohydrates  in  the  form  of  starch  will  not  be 
acceptable,  when  by  being  converted  into  soluble  starch,  dextrin, 
or  maltose  they  will  not  only  be  well  digested,  but  will  bring  about  a 
marked  improvement  in  general  conditions.  Many  of  the  proprietary 
infant  foods  are  made  in  whole  or  in  part  of  cereals  which  have  been 
treated  so  as  to  affect  the  properties  of  their  carbohydrates,  or  starch. 
The  amount  of  cellulose  in  cereals  is  very  small.  Details  for  pre- 
paring cereals  for  infants  will  be  found  at  page  151. 


Eggs. 

Eggs. — These  are  to  the  animal  kingdom  what  the  cereals  are  to 
the  vegetable  kingdom — a  germ  with  material  which  it  can  use  in  form- 
ing an  animal  organism  which  is  capable  of  digesting  food  from  other 
sources.  As  the  animal  tissues  are  almost  entirely  made  up  of  pro- 
teins and  water,  eggs  naturally  are  likewise  composed  principally  of 
proteins  and  water.  They  also  contain  fat,  and  lecithin  from  which 
nerve  tissue  may  be  formed,  and  organic  iron  for  blood  formation: 
Eggs  of  different  animals  var}^  in  composition  according  to  the  devel- 
opment of  the  young  when  hatching  takes  place.  Hen's  eggs  are  the 
ones  principally  used  and  these  contain  enough  of  the  food  elements 
in  suitable  form  to  make  all  kinds  of  tissues,  as  the  chick  comes  out 
of  the  egg  fully  formed,  and  its  growth  then  consists  almost  entirely 
of  enlargement. 

Eggs,  therefore,  are  very  useful  additions  to  diet  during  the 
growing  period,  and  especially  w^hen  the  infant  is  beginning  to  eat  table 
food  and  needs  easily  digested  proteins. 


122  DISEASES  OF  CHILDREN. 

Proprietary  Infant  Foods. 

General  Properties. — Before  the  subject  of  infant-feeding  was  as 
well  understood  as  it  is  at  present,  many  attempts  were  made  to  fur- 
nish artificial  foods  which  should  take  the  place  of  mother's  milk  and 
of  cow's  milk.  For  a  time  they  served  a  useful  purpose  and  when  it 
was  impossible  to  obtain  a  supply  of  good  cow's  milk  they  were  of 
considerable  value,  as  very  often  they  were  retained  and  saved  the 
infants  from  starvation  or  serious  digestive  disturbance  caused  by 
contaminated  milk.  On  them  many  infants  gained  in  weight  and 
thrived  temporarily,  but  frequently  these  infants  developed  rickets 
and  scurvy,  or  were  poorly  developed  and  of  feeble  constitution,  and 
consequently  were  carried  off  by  the  first  serious  sickness.  All  of 
these  foods  are  composed  of  proteins,  mineral  matter,  fats,  and  car- 
bohydrates. In  some  the  amount  of  fat  is  infinitesimal,  the  protein 
low  in  quantity  and  the  carbohydrates  very  high.  None  of  them  are 
at  all  like  mother's  milk  in  properties.  They  often  contain  only 
enough  protein  to  but  little  more  than  make  up  for  metabolic  waste, 
but  the  carbohydrates  are  in  such  a  form  that  they  are  easily  assimi- 
lated and  converted  into  fat  which  causes  increase  in  weight. 

All  of  the  proprietary  infant  foods  are  composed  of  cereals,  sugars, 
dried  milk,  and  eggs,  either  singly  or  in  combinations  that  have  under- 
gone special  treatments.  Chemical  analyses  show  little  or  none  of  their 
properties  except  their  possible  nutritive  value.  The  most  recent 
analyses  available  are  given  on  page  123  and  are  taken  from  the  1908 
report  of  the  Connecticut  Agricultural  Experiment  Station. 

Classification  of  Proprietary  Infant  Foods.— A  clear  idea  of  what 
the  infant  foods  on  the  market  are  like  will  be  obtained  if  they  are 
classified  according  to  the  materials  from  which  they  are  made,  and 
according  to  this  plan  they  will  all  fall  into  about  three  or  possibly 
four  distinct  groups  or  classes,  as  follows: 


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1 

MATERIALS  USED  IN   SUBSTITUTE  FEEDING.  125 

The  composition  of  the  food  when  it  is  in  the  infant's  bottle  will 
depend  absolutely  on  how  much  of  the  proprietary  food  is  used  or 
on  the  richness  and  quantity  of  milk  to  which  it  is  added.  Thus  it  is 
manifestly  impossible  to  give  analyses  which  will  give  a  correct  idea  of 
the  nutritive  value  of  these  mixtures. 

There  is  one  point,  however,  which  should  become  fixed  in  the 
mind  and  that  is  that  nearly  all  of  the  proprietary  foods  are  com- 
posed of  carboh\^drates  mostly,  and  these  carbohydrates  are  largely  if 
not  entirely  derived  from  cereals.  Gain  in  weight  is  often  made  on 
these  foods,  but  unless  they  are  reinforced  by  milk  the  tissues  are  not 
of  the  firm  muscular  character  produced  by  foods  richer  in  proteins. 

Sometimes,  as  when  traveling  or  when  a  good  quality  of  milk 
cannot  be  obtained,  the  foods  that  are  to  be  used  without  fresh  milk 
may  serve  a  useful  purpose.  But  for  general  purposes  of  feeding  these 
foods  possess  disadvantages  over  food  mixtures  for  which  the  physician 
can  write  prescriptions  to  be  followed  by  the  mother  or  nurse,  after 
he  has  become  familiar  with  the  principles  and  methods  of  artificial 
feeding. 


CHAPTER  XV. 
RISE   AND   DEVELOPMENT  OF  SCIENTIFIC  INFANT-FEEDING. 

Historical. — The  experience  of  many  successful  pediatricians  in 
all  parts  of  the  world  showed  that  infants  did  much  better,  as  a  rule, 
if  part  of  their  food  was  fresh  milk  of  some  kind,  but  it  was  also 
found  that  there  was  no  animal  that  secreted  milk  having  exactly  the 
same  properties  as  human  milk.  Therefore  attempts  were  made  to 
make  cow's  and  goat's  milk,  which  were  the  milks  most  available, 
correspond  to  human  milk  in  composition  and  properties.  Human 
milk  was  analyzed,  as  were  also  the  other  milks,  and  it  was  found 
their  composition  was  apparently  the  same,  except  that  the  propor- 
tions of  the  ingredients  varied.  Cow's  milk  was  richer  in  protein 
which  formed  curds  in  the  stomach,  so  there  arose  the  process  of 
diluting  milk  for  infant-feeding.  It  was  found  that  diluting  the 
milk  with  gruels  made  from  cereals  increased  its  digestibility  by 
softening  the  curds.  Later,  it  was  discovered  that  if  milk  was  pepton- 
ized the  curds  would  not  form,  or  if  the  milk  was  only  partially 
peptonized  the  curds  formed  were  very  small,  and  peptonized  milk 
for  infants  was  looked  upon  as  the  solution  of  the  problem.  The 
action  of  bacteria  on  milk  was  recognized,  and  then  sterilization, 
heating  milk  to  212°  F.,  was  introduced.  After  a  time  it  was  observed 
that  sterilizing  unfavorably  affected  the  milk,  and  pasteurization  or 
heating  the  milk  from  150°  to  165°  F.  was  introduced.  These  proc- 
esses did  a  great  deal  of  good  under  certain  conditions,  but  the 
problem  was  not  yet  completely  solved. 

It  had  been  observed  that  human  milk  was  slightly  alkaline 
and  cow's  milk  amphoteric,  that  is,  both  alkaline  and  acid,  when  tested 
with  litmus-paper,  and  as  the  addition  of  lime-water  or  bicarbonate 
of  sodium  to  the  food  often  made  it  agree,  the  conclusion  was  drawn 
that  the  important  difference  between  human  milk  and  cow's  milk 
was  in  their  reactions  to  litmus-paper,  and  the  routine  addition  of 
lime-water  or  baking  soda  to  the  food  was  looked  upon  as  a  funda- 
mental process. 

After  a  time  it  was  taught  that  all  milks  were  composed  of  the 
same  substances,  and  that  their  differences  were  due  merely  to 
different  percentages  of  the  various  ingredients  and  unlike  reactions. 

126 


RISE  AND  DEVELOPMENT  OF  SCIENTIFIC  INFANT-FEEDING.        127 

This  teaching  was  widely  accepted  by  many  pediatricians,  but  it 
was  observed  that  it  was  not  always  applied  in  practice  by  its  expon- 
ents. When  this  fact  became  recognized,  a  new  theory  was  brought 
forward,  that  the  difference  between  human  milk  and  cow's  milk  was 
due  to  the  relative  proportions  of  casein  (the  portion  of  the  protein 
which  is  solidified  by  rennin)  and  albumin  present  in  each,  but  this 
theory  has  been  seen  to  be  untenable,  as  it  was  found  that  caseins  differ 
in  properties  and  that  the  term  casein  is  about  as  specific  as  the  term 
wood. 

Since  the  subject  of  infant-feeding  has  been  approached  from 
the  biological  standpoint,  the  fallacy  of  the  theories  of  making  human 
milk  from  cow's  milk,  as  has  been  taught,  has  become  quite  apparent ; 
but  as  all  of  these  theories  and  teachings  have  been  brought  forward 
within  comparatively  few  years  and  have  been  supported  by  author- 
ities, and  will  be  met  in  practice  for  many  years  to  come,  an  outline 
will  be  given  showing  wherein  some  of  them  are  wrong  and  the  prin- 
ciples upon  which  they  are  based. 

Fundamental  Errors  Made. — When  the  theory  was  put  forth  that 
the  differences  between  human  milk  and  cow's  milk  were  due  to  un- 
like percentage  composition  and  reaction  to  litmus,  two  important 
errors  were  made.  In  determining  the  comparative  properties  of  the 
solids  made  from  the  proteins  of  the  two  milks,  acid  was  added  to 
the  milks,  and  rennin,  or  the  gastric  secretion  of  young  animals  with 
which  the  milk  would  come  in  contact  in  the  stomach,  was  rejected 
as  being  an  unsatisfactory  reagent.  The  effect  on  milk  of  adding 
acid  is  totally  different  from  that  produced  by  the  addition  of  rennin. 
The  milk  does  not  meet  enough  acid  in  the  young  stomach  to  precipi- 
tate it,  but  rennin  which  solidifies  it  is  present;  so  this  basis  of  compari- 
son was  not  only  erroneous,  but  misleading,  Acid  will  make  a  fine 
precipitate,  while  rennin  makes  a  solid  mass  from  cow's  milk. 

It  was  laid  down  as  a  fundamental  principle  that  the  addition  of 
5  per  cent,  of  lime-water  to  whole  milk  gave  it  the  same  reaction  as 
human  milk  and  that  this  quantity  was  the  proper  amount  to  add 
to  milk  for  infants.  It  was  also  taught  that  one  to  two  grains  of  bi- 
carbonate of  sodium  to  each  ounce  of  infant's  food  produced  the  same 
result.  But  when  it  came  to  actual  practice,  5  to  10  per  cent,  of  lime- 
water  was  to  be  added  to  diluted  milk.  Thus  it  came  about  that  any- 
where from  40  to  100  per  cent,  of  lime-water  was  added  to  the  actual 
whole  milk  used  in  preparing  the  food  for  an  infant,  as  is  seen  in  the 
following  example  of  a  food  mixture  often  employed: 

Milk  one  ounce,  lime-water  one  ounce,  sugar  one  ounce,  water  eighteen  ounces. 
Total,  twenty  fiuidounces.     Five  per  cent,  of  the  food,  or  one  ounce,  is  lime-water 


128  DISEASES  OF  CHILDREN. 

but  this  one  ounce  is  100 per  cent,  of  the  milk  actually  employed.  If  two  ounces 
of  milk  were  used  instead  of  one  ounce,  the  percentage  of  lime-water  in  the  food 
would  still  be  5  per  cent.,  but  it  would  equal  50  per  cent,  of  the  milk.  If  10  per 
cent,  lime-water  was  added,^  as  has  often  been  recommended,  in  the  first  case  the 
percentage  of  lime-water  to  milk  would  be  200  per  cent,  and  100  per  cent,  in  the 
second  instance. 

When  lime-water  is  added  to  cow's  milk  it  alters  the  casein  so  that 
it  will  not  form  a  solid  with  the  rennin  of  the  stomach. 

Litmus  is  not  a  proper  indicator  to  use  in  taking  the  reaction  of 
milk  as  it  is  an  acid  itself,  stronger  than  some  of  the  acids  of  milk, 
the  presence  of  which  it  fails  to  show.  Casein  is  an  acid,  and  when 
rubbed  in  a  mortar  with  calcium  carbonate  will  drive  off  the  carbonic 
acid  (Van  Slyke).  Some  of  the  acidity  of  fresh  milk  is  due  to  casein, 
and  also  to  the  phosphate  of  calcium  present. 

For  testing  the  reaction  of  milk,  phenolphthalein  (1  percent,  alco- 
holic solution)  should  be  used  instead  of  litmus,  and  with  this  indicator 
breast-milk  is  also  found  to  be  acid  in  reaction.  When  lime-water  is 
added  to  fresh  cow's  milk  it  is  found  that  about  70  to  90  per  cent,  is 
required  to  make  the  milk  alkaline  to  phenolphthalein.  Breast-milk 
needs  from  8  to  24  per  cent,  lime-water  to  make  it  alkaline.  The  effect 
of  adding  lime-water  in  such  quantities  as  mentioned  above  is  to 
modify  the  physical  and  digestive  properties  of  the  casein  in  the  in- 
fant's stomach. 

If  bicarbonate  of  sodium  is  added  to  the  foregoing  mixtures  in  the 
quantities  often  stated  to  be  the  equivalent  of  5  per  cent,  of  lime- 
water,  that  is,  one  to  two  grains  to  the  ounce  of  food,  twenty  to  forty 
grains  would  be  added  to  twenty  ounces  of  food. 

If  there  was  one  ounce  of  milk  in  the  twenty  ounces  there  would  be  added  to 
it  for  the  purpose  of  making  it  alkaline  twenty  to  forty  grains  of  bicarbonate  of 
sodium,  or  at  the  rate  of  six  hundred  and  forty  to  twelve  hundred  and  eighty 
grains,  or  approximately  one  and  one-half  to  three  ounces  to  the  quart  of  fresh 
milk.  As  one  quart  of  soured  milk  will  be  neutralized  by  about  one  hundred  and 
twenty  grains  of  bicarbonate  of  soda,  the  error  of  adding  at  the  rate  of  eight  to 
sixteen  times  as  much  to  fresh  milk  will  be  apparent.  If  bicarbonate  of  sodium 
was  to  be  added  in  such  quantity  as  to  equal  lime-water  in  power  to  neutralize 
acid,  about  three  and  one-half  grains  would  be  needed  to  replace  one  ounce 
of  lime-water.  Instead  of  this  quantity  twenty  to  forty  grains  have  been 
recommended. 

Forty  grains  of  bicarbonate  of  sodium  will  neutralize  abovit  twenty  ounces 
of  the  gastric  juice  of  the  adult,  containing  0.2  per  cent,  hydrochloric  acid. 
One  ounce  of  lime-water  will  neutralize  a  little  less  than  one  ounce  of  such 
gastric  juice.  As  the  gastric  juice  of  infants  is  weak  in  acid,  it  is  evident  that 
the  addition  of    these  alkalies    to  the    food    has  the    effect  of  neutralizing  the 


RISE  AND  DEVELOPMENT  OF  SCIENTIFIC  INFANT-FEEDING.        129 

gastric  secretion,  and  preventing  stomach  digestion.  The  food  remains  fluid  and 
is  passed  into  the  intestines  and  digested  there.  These  addition^  retard  stomach 
development,  and  in  lower  animals  have  been  found  to  lessen  the  amount  of 
nutriment  assimilated  from  a  given  quantity  of  food. 

It  will  be  seen  that  under  the  supposition  that  cow's  milk  was 
being  made  like  human  milk  in  its  properties  by  altering  its  reaction, 
an  entirely  different  effect  was  being  produced,  which  goes  to  show  the 
importance  of  not  being  too  easily  carried  away  by  plausible  theories, 
and  of  checking  off  standards  based  entirely  on  chemical  data.  In  this 
instance  an  error  in  chemistry  was  made. 

Now  that  these  errors  have  become  recognized  the  alkalies  are 
used  with  the  understanding  of  their  action  and  effect  and  their  routine 
use  is  not  considered  as  advisable  as  formerly. 

Similar  errors  were  made  in  the  theory  that  the  differences  be- 
tween human  milk  and  cow's  milk  were  due  to  unlike  percentages  of 
casein  and  albumin,  which  w^ere  supposed  to  be  constant  for  each 
kind  of  milk.  It  has  been  stated  with  great  confidence  that  there  was 
one  part  of  albumin  to  five  parts  of  casein  in  cow's  milk  and  two  parts 
of  albumin  to  one  part  of  casein  in  human  milk.  Van  Styke  who  has 
made  an  exhaustive  study  of  this  subject  in  the  milk  of  hundreds  of 
cows  s^pplying  milk  for  cheese-making,  which  is  based  on  the  solidify- 
ing of  casein  by  rennin,  found  there  was  no  fixed  relation  between 
casein  and  albumin.  It  varied  in  herd  milk  from  2.6  to  5.6  parts  of 
casein  to  one  part  of  albumin.  The  proportion  is  different  in  the 
various  breeds  of  cows  and  in  the  individuals  of  the  breeds,  and  it  also 
is  different  at  different  seasons  of  the  year.  In  two  Jersey  cows  the 
proportions  were  3.7  and  6.3  parts  of  casein  to  one  of  albumin,  and  in 
two  Holstein-Friesian  cows  they  were  3.2  and  4.4  to  1. 

In  addition  to  these  wide  fluctuations  it  should  be  remembered 
that  caseins  are  not  alike,  so  this  basis  has  an  insecure  foundation  to 
rest  upon.  In  practice,  when  this  theory  is  applied,  a  portion  of  the 
casein  of  the  cow's  milk  is  removed  and  alkali  is  added  to  the  remain- 
ing amount  which  throws  it  into  the  intestine  for  digestion. 

These  different  methods  of  supposedly  making  human  milk  from 
cow's  milk  have  all  fallen  under  the  heading  of  "  modifying  milk."  As 
a  matter  of  fact,  none  of  the  methods  resulted  in  making  human  milk, 
and  some  of  them  were  wide  of  the  mark.  Those  who  study  the  sub- 
ject carefully  will  see  that  what  actually  takes  place  in  all  of  the 
methods  of  feeding  which  have  been  proposed  is  an  adaptation  of  the 
food  to  the  infant  by  one  means  or  another.  Milk  is  modified  by  all 
methods,  but  the  principles  involved  differ  widely.  The  following 
classification  will  be  found  helpful. 
9 


130  DISEASES  OF  CHILDREN. 

Classification  of  Methods  of  Modifying  Milk  for  Infant-feeding. — 

All  methods  of  modifying  cow's  milk  for  infant  feeding  naturally 
fall  into  seven  groups,  according  to  the  principle  involved : 

Group  1.  Methods  that  affect  the  quantitative  composition  of 
cow's  milk. 

(a)  Simple  dilution  with  water;  (6)  dilution  with  water  with  the  addition 
of  cream  and  sugar;  (c)  removal  of  a  portion  of  the  casein  by  adding  rennin  and 
then  straining  out  the  solidified  casein  or  a  portion  of  it. 

Group  2.  Methods  in  which  the  character  of  the  proteins  of  cow's 
milk  are  so  altered  that  the  rennin  of  the  stomach  will  not  solidify  the 
milk. 

(a)  Addition  of  lime-water  until  alkaline  to  phenolphthalein  (5  to  10  per  cent, 
of  the  food);  (b)  addition  of  carbonate  of  potassium  until  slightly  alkaline  {\ 
grain  to  ounce  of  milk).  If  the  stomach  secretes  enough  acid  to  neutralize  these 
additions  the  milk  will  solidify. 

Group  3.  Methods  that  retard  the  solidification  of  milk  by  rennin 
and  also  neutralize  any  acid  that  may  be  secreted  by  the  stomach. 

(a)  Addition  of  1  to  2  grains  of  bicarbonate  of  sodium  to  each  ounce  of  food; 
(b)  addition  of  syrup  of  lime;  (c)  addition  of  magnesium  hydrate.  These  additions 
tend  to  prevent  all  gastric  digestion  and  to  throw  the  entire  work  of  digestion  on 
the  intestines.     . 

Group  4.  Methods  in  which  the  casein  is  precipitated  in  fine 
particles  by  acids. 

(a)  Buttermilk  feeding;  (6)  kumyss  feeding;  (c)  matzoon  feeding;  (d)  addition 
of  dilute  hydrochloric  acid.  In  buttermilk  feeding,  lactic  bacteria  naturally  in 
the  milk,  or  those  that  may  be  added  are  allowed  to  grow  and  produce  lactic  acid 
which  precipitates  the  casein.  If  the  buttermilk  is  boiled  before  feeding,  as  it  is 
sometimes,  the  bacteria  will  be  killed,  otherwise  bacteria  are  also  given  in  enormous 
numbers  which  may  sometimes  prove  beneficial.  In  kumyss  and  matzoon 
feeding,  bacteria  produce  acid  which  precipitates  the  casein.  Yeasts  may  also 
be  present. 

Any  pepsin  that  may  be  secreted  can  readily  act  upon  the  proteins  in  the 
presence  of  the  acids.     Such  foods  may  encourage  gastric  digestion. 

Group  5.  Methods  that  profoundly  alter  the  character  of  the  milk. 

(a)  Peptonization  of  milk;  (b)  addition  of  1  to  2  grains  of  citrate  of  sodium  or 
potassium  to  each  ounce  of  milk  employed. 

Peptonization  completely  alters  the  character  of  the  proteins  of  the  milk. 
Casein  is  in  some  way  combined  with  calcium  in  milk.  Citrate  of  sodium  or 
potassium  when  added  to  milk  produce  citrate  of  calcium  and  caseinate  of  sodium 
or  potassium,  which  will  not  form  a  solid  with  rennin.  The  calcium  citrate  is 
soluble  in  an  excess  of  the  precipitant  and  remains  in  solution.  -Acids  added  to 
milk  in  which  the  casein  is  in  combination  with  ammonium,  sodium,  potassium, 
or  lithium  will  produce  a  precipitate  of  casein  like  that  of  sour  milk.  Peptonized 
milk  also  remains  fluid  in  the  stomach. 


RISE  AND  DEVELOPMENT  OF  SCIENTIFIC  INFANT-FEEDING.         131 

Group  6.  Methods  that  indirectly  alter  the  properties  of  the  milk. 

(a)  Sterilizing,  boiling,  or  scalding  the  milk;  (6)  pasteurizing  the  milk; 
(c)  using  condensed  or  evaporated  milk. 

Heating  milk  in  some  way  changes  it  so  the  rennin  ferment  does  not  cause  it 
to  solidify  as  firmly  or  as  promptly  as  does  fresh  milk,  and  it  also  destroys  bacteria 
that  might  produce  acid  which  would  accelerate  the  action  of  the  rennin  in  solidi- 
fying the  milk. 

Group  7.  Methods  that  mechanically  alter  the  character  of  the 
solidified  milk  without  affecting  the  action  of  the  digestive  secretions. 

(a)  Diluting  the  milk  with  cereal  gruels  in  which  the  starch  is  in  a  gelatinized 
condition;  (b)  diluting  the  milk  with  cereal  gruels  in  which  the  starch  has  been 
converted  into  soluble  starch,  dextrin,  and  maltose. 

Laboratory   Demonstrations    to    Illustrate   the  Effect  of   Various 
Methods  of  Modifying  Cow's  Milk. 

As  the  literature  of  infant-feeding  abounds  with  contradictory 
-statements,  concerning  the  effect  of  these  different  additions  to  milk, 
it  is  important  that  first-hand  knowledge  should  be  obtained,  which 
may  easily  be  had  by  performing  the  following  experiments.  Time 
spent  in  doing  them  will  be  well  expended  and  will  aid  greatly  in 
understanding  many  processes  employed,  and  conditions  met  in 
practical  feeding. 

Experiment  1. — Shows  amount  of  lime-water  required  to  neutralize  cow's  milk 
and  breast-milk. 

(a)  Make  a  1  per  cent,  alcoholic  solution  of  phenolphthalein.  An  ounce  or 
even  ten  cubic  centimeters  will  be  enough,  (b)  Obtain  some  lime-water,  (c)  Place 
one  drop  of  the  phenolphthalein  solution  in  a  porcelain  dish  and  add  a  few  drops 
of  lime-water.  It  should  turn  bright  red.  (d)  Pour  ten.  cubic  centimeters  of 
fresh  milk  into  a  clean  dish,  (e)  Add  one  or  two  drops  of  the  phenolphthalein 
solution  and  stir  with  a  glass  rod  a  few  times.  (/)  Measure  into  a  graduate  or  a 
graduated  pipette,  ten  cubic  centimeters  of  lime-water,  (g)  Add  lime-water  to 
'  the  ten  cubic  centimeters  of  milk  to  which  the  phenolphthalein  was  added,  one 
cubic  centirneter  at  a  time,  and  stir  constantly  until  the  milk  becomes  slightly 
pink  in  color.  This  indicates  that  the  mixture  has  become  alkaline.  The  number 
of  cubic  centimeters  of  lime-water  added  multiplied  by  ten  will  give  the  percentage 
of  lime-water  required  to  overcome  the  acid  reaction  of  the  milk.  Anywhere  from 
five  to  nine  cubic  centimeters  of  lime-water  will  be  needed,  which  equals  50  to  90 
per  cent,  of  the  milk.  If  convenient,  allow  some  of  the  same  milk  to  remain  over- 
night in  a  warm  room  to  develop  acid  by  souring  and  then  see  how  much  lime- 
water  is  required  to  make  the  milk  turn  pink  after  phenolphthalein  has  been 
added.  As  high  as  200  or  300  per  cent,  may  be  needed,  depending  upon  how 
far  the  souring  process  has  proceeded. 

If  possible  procure  a  specimen  of  breast-milk  and  test  as  above.  Anywhere 
from  10  to  25  per  cent,  lime-water  will  be  required  to  make  it  turn  pink. 

It  will  also  be  instructive  to  use  red  and  blue  litmus-paper  in  making  these 
tests,  especially  so  if  different  lots  of  litmus-paper  are  used.     It  will  be  found  that 


132  DISEASES  OF  CHILDREN. 

most  discordant  results  will  be  obtained.  The  litmus  is  not  as  sensitive  as  the 
phenolphthalein  and  will  not  give  same  results,  and  with  different  makes  or  lots 
of  litmus-paper  the  same  mixture  may  be  shown  to  be  acid,  neutral,  or  alkaline, 
and  the  quantity  of  lime-water  required  to  neutralize  the  same  milk  may  vary 
widely  if  different  lots  of  litmus  are  used.  For  this  reason  litmus  should  not  be 
used  in  determining  acidity  in  milk  and  results  should  not  be  accepted  as  final 
unless  phenolphthalein  is  used  as  the  indicator. 

The  acidity  of  milk  that  causes  trouble  in  infant-feeding  is  not  that  natural 
to  the  milk,  but  is  that  resulting  from  bacterial  action  after  milk  has  been  drawn. 
This  distinction  should  ever  be  kept  in  mind.  Alum  when  dissolved  in  water 
will  have  an  acid  reaction;  borax  when  in  solution  will  have  an  alkaline  reaction. 
This  does  not  mean  that  alkali  should  be  added  to  the  alum  or  acid  to  the  borax 
solution  to  neutralize  them.  These  reactions  are  caused  by  the  alum  and  borax 
being  hydrolyzed  by  the  water,  and  any  salt  of  a  strong  acid  with  a  weak  base  will 
have  an  acid  reaction,  and  any  salt  of  a  strong  base  with  a  weak  acid  will  have  an 
alkaline  reaction  when  dissolved  in  water.  If  solutions  of  alum  and  borax  are 
mixed  in  different  proportions,  the  mixture  can  be  made  to  have  acid,  neutral 
or  alkaline  reaction,  and  some  solutions  that  are  neutral  may  be  made  acid  or 
alkaline  by  addition  of  water.  Compounds  having  similiar  properties  exist  in 
natural  milk,  and  if  it  was  known  just  what  these  compounds  were,  it  might  be 
possible  to  adjust  the  milks  to  be  alike.  In  some  milks  the  bases  are  stronger 
than  in  others  and  hence  some  milks  show  less  acid  reaction  than  others,  although 
in  all  milks  it  will  be  found  the  acid  reaction  predominates.  To  those  familiar 
with  chemistry  this  slight  difference  of  reaction  in  milks  would  be  looked  upon  as 
of  no  practical  value  or  significance,  the  real  important  thing  from  the  chemist's 
standpoint  would  be  to  know  what  causes  the  difference.  As  a  very  slight  change 
in  the  salts  or  mineral  matter  of  the  milk  might  alter  its  reaction,  too  much  im- 
portance should  not  be  attached  to  reactions  oi  fresh  milk. 

Experiment  2. — Shows  some  effects  of  use  of  bicarbonate  of  sodium:  Take  a 
few  grains  of  bicarbonate  of  sodium  and  dissolve  in  a  little  water  in  a  test-tube. 
Add  a  drop  of  the  phenolphthalein  solution  and  also  test  with  a  strip  of  red  or 
neutral  litmus-paper.  If  the  bicarbonate  of  sodium  is  quite  pure  it  will  be  neutral 
or  slightly  alkaline.  Now  boil  the  solution  for  a  few  minutes  and  then  Cool  it. 
Test  again  with  the  phenolphthalein  and  litmus.  The  solution  will  be  found  to  be 
intensely  alkaline. 

This  test  is  instructive  in  that  it  shows  what  will  take  place  in  milk  or  infant's 
food  to  which  bicarbonate  of  sodium  has  been  added  if  it  is  pasteurized,  sterilized, 
or  scalded.  The  sodium  bicarbonate  is  decomposed,  some  of  the  carbonic  acid 
being  driven  off  and  carbonate  of  sodium  remains  which  is  decidedly  alkaline. 
It  is  the  familiar  "'  washing  soda."  Some  of  the  feeding  mixtures  that  have  been 
recommended,  which  contain  large  quantities  of  bicarbonate  of  sodium,  when 
boiled,  become  mixtures  of  washing  soda  and  milk.  If  one  of  these  mixtures  is 
made  and  well  boiled  and  then  swallowed  by  the  physician,  he  will  think  twice 
before  ordering  it  for  an  infant. 

Experiment  3. — Shows  effect  of  rennin  on  milk.  Obtain  from  a  druggist 
some  "liquid  rennet,"  which  is  an  extract  of  a  young  calf's  stqmach.  Now  se- 
cure some  fresh  cow's  milk  and  test  it  for  acidity  with  lime-water,  as  in  experi- 
ment 1,  to  be  sure  there  is  no  acidity  caused  by  souring.  If  the  milk  takes  more 
than  90  per  cent,  of  lime-water  to  cause  it  to  turn  pink  after  the  phenolphtha- 
lein has  been  added,  incipient  souring  should  be  suspected. 


RISE  AND  DEVELOPMENT  OF  SCIENTIFIC  INFANT-FEEDING.        133 

Add  to  about  an  ounce  or  two  of  the  fresh  milk  two  or  three  drops  of  the 
liquid  rennet  and  pour  from  one  vessel  into  another  to  cause  a  thorough  mixture. 
Put  in  a  beaker  or  cup  and  place  in  a  dish  of  warm  water  to  warm  the  milk  to 
about  body  temperature.  If  the  milk  contains  no  preservatives  or  foreign  salts 
or  has  not  been  kept  long  in  rusty  cans,  it  will  soon  form  a  limpid  jelly  and  in  a 
few  minutes  become  quite  solid.  This  is  the  first  step  in  the  digestion  of  milk  and 
is  what  takes  place  in  the  stomach.  The  solid  will  soon  begin  to  shrink  and  a 
greenish-yellow  fluid  will  exude.  This  is  known  as  "whey "and  contains  the 
albumin,  sugar,  and  some  of  the  salts  of  the  milk. 

'  Experiment  4. — Shows  difference  between  acid  and  rennin  curds.  Make  some 
very  dilute  hydrochloric  acid  and  add  it  slowly  a  few  drops  at  a  time  to  two  ounces 
of  the  milk  and  stir  until  the  milk  precipitates.  This  precipitate  is  not  like  the 
solid  formed  by  the  rennet,  which  is  composed  of  the  casein  of  the  milk  in  com- 
bination with  calcium  in  some  form.  The  precipitate  formed  by  the  acid  is  a 
combination  of  casein  and  acid  and  has  entirely  different  digestive  as  well  as 
physical  properties. 

Now  add  to  about  two  ounces  of  the  milk  about  one-third  as  much  dilute 
hydrochloric  acid  as  was  required  to  precipitate  it,  but  be  sure  the  milk  is  not 
curdled  after  the  acid  is  added.  Then  add  two  or  three  drops  of  the  liquid  rennet 
and  mix  as  before  and  place  in  a  beaker  or  cup  in  warm  water. 

It  will  be  observed  that  the  milk  solidifies  much  more  rapidly  than  the  fresh 
milk  without  the  acid  did,  and  becomes  firmer.  The  acid  accelerates  the  action  of 
the  rennin. 

This  fact  has  a  wide  importance  in  infant-feeding,  for  lactic  bacteria  if  allowed 
to  grow  in  the  milk  produce  acid  all  through  the  milk  very  much  as  yeast  pro- 
duces gas  in  bread  dough.  In  hot  weather  conditions  are  such  that  these  bacteria 
produce  acid  in  the  milk  very  rapidly.  If  the  milk  is  given  to  the  infant  it  so- 
lidifies quickly  and  acid  is  constantly  produced  in  the  solid  mass  in  the  stomach, 
which  causes  it  to  become  tough,  stringy,  and  indigestible.  The  result  is  the 
infant  vomits  stringy  curds  or  they  are  found  in  the  stools,  the  infant  suffering  at 
the  same  time  with  colic.  If  milk  is  heated  or  pasteurized,  the  acid-producing 
bacteria  are  destroyed.  Consequently  in  summer  time  it  is  often  advantageous 
to  pasteurize  milk  if  the  milk  is  not  fresh  or  cannot  be  kept  cool  enough  to  prevent 
development  of  acid  (under  50°  F.).  However,  if  clean  milk  of  low  bacterial 
count  is  obtainable,  and  it  can  be  kept  on  ice  until  ready  for  use,  there  will  be  no 
necessity  for  pasteurizing  to  retard  development  of  acid.  This  has  been  demon- 
strated on  a  large  scale  in  tenement-house  feeding  where  the  preparation  of  the 
food  was  in  the  hands  of  trained  physicians  who  could  see  that  the  food  was 
properly  cared  for  up  to  the  time  it  was  given  to  the  infant. 

Experiment  5. — Shows  how  various  additions  to  milk  retard  action  of  rennin. 
In  small  beakers  or  cups  make  the  following  mixtures: 

2  oz.  fresh  milk  plus  1  oz.  boiled  water. 

2  oz.  boiled  milk  plus  1  oz.  boiled  water. 

2  oz.  fresh  milk  plus  1  oz.  lime-water. 

2  oz.  fresh  milk  plus  1  oz.  water  plus  2  grains  of  carbonate  potassium. 

2  oz.  fresh  milk  plus  1  oz.  water  plus  12  grains  bicarbonate  sodium. 

2  oz.  fresh  milk  plus  1  oz.  water  plus  6  grains  citrate  sodium. 

It  is  well  to  number  the  beakers  so  that  they  shall  not  become  confused. 
Allow  to  stand  about  five  minutes  to  insure  solution  and  then  pour  each  mixture 
from  one  vessel  into  another  a  few  times  to  secure  uniform  mixing. 


134         '  DISEASES  OF  CHILDREN. 

Now  add  to  each  beaker  two  or  three  drops  of  the  liquid  rennet,  mix  thoroughly 
and  set  all  into  warm  water  and  see  how  long  it  takes  the  milk  to  solidify.  Some 
of  them  will  never  solidify,  i.e.,  those  with  lime-water,  carbonate  of  potassium  and 
citrate  of  sodium.  The  specimen  containing  bicarbonate  of  sodium  may  solidify, 
but  if  acid  is  added  an  effervescence  of  gas  will  take  place,  showing  the  bicarbonate 
had  not  been  decomposed  by  the  acidity  of  the  milk,  and  that  it  is  present  to  neu- 
tralize any  acid  in  the  stomach.  If  this  specimen  had  been  heated  it  would  not 
have  solidified,  as  the  bicarbonate  wpuld  have  been  changed  into  carbonate  which 
is  highly  alkaline. 

These  foregoing  experiments  will  show  how  the  different  chemical  modi-' 
fications  of  milk  alter  its  character  and  behavior  with  the  digestive  secretions. 
It  is  well  to  state  here  that  gastric  digestion,  when  it  is  established,  consists  in  the 
action  of  pepsin  and  acid  on  proteins,  and  that  pepsin  does  not  act  in  the  absence 
of  acid.  It  is  obvious,  then,  that  those  modifications  of  milk  which  contain  large 
amounts  of  alkalies  will  greatly  retard  or  prevent  gastric  digestion.  A  glance  over 
the  paragraph  on  classification  of  methods  of  modifying  milk  will  be  helpful  after 
performing  these  experiments. 

Infants  Tend  to  Adapt  Themselves  to  Their  Food. — One  of  the 

inherent  faculties  possessed  by  all  forms  of  living  things  is  the  ability 
to  change  their  form  and  functions,  to  bring  themselves  into  harmony 
with  new  or  altered  conditions  of  life,  if  the  altered  conditions  are 
brought  about  gradually.  The  development  of  callous  on  the  hands  of 
one  unused  to  manual  labor  as  soon  as  rough  materials  are  handled  is  a 
familiar  illustration  of  this  fact.  The  acquirement  of  tolerance  for 
drugs,  and  immunity  to  certain  diseases  after  one  infection  are  other 
illustrations. 

Similarly,  the  feeding  or  nutritional  habits  of  animals  can  be 
modified  to  a  greater  or  less  extent.  It  is  possible  by  careful  manage- 
ment to  develop  in  a  carnivorous  animal  herbivorous  habits  of  feeding, 
as  is  often  seen  in  house  cats  which  are  fed  exclusively  on  vegetable 
food.  The  one  thing  to  be  avoided  in  such  feeding  is  too  radical  and 
too  sudden  changes  in  the  form  of  the  food,  as  the  animal  then  does 
not  have  sufficient  time  to  adapt  itself  to  the  new  conditions. 

In  infants  this  ability  of  adaptation  to  the  food  is  present  to  a 
marked  degree,  and  much  of  the  credit  that  goes  to  the  successful 
feeder  is  due  to  the  unconscious  cooperation  of  the  infant,  brought 
about  by  making  the  changes  in  food  gradually,  giving  it  time  to  adapt 
itself  to  new  food  conditions.  Those  in  which  the  power  of  adapta- 
tion is  dormant  form  the  greater  number  of  the  difficult  feeding  cases. 

It  is  also  due  to  this  power  of  adaptation  that  some  infants 
can  survive  and  grow  on  food  that  would  kill  other  children.  There 
is  a  limit  to  this  faculty,  however,  and  it  is  more  strongly  developed 
in  some  infants  than  in  others.  When  properly  utilized  it  is  of  great 
assistance  to  the  physician,  but  it  should  not  be  abused  by  allowing 
any  kind  of  food  to  be  given  and  trusting  to  the  infant  to  get  used  to  it. 


RISE  AND  DEVELOPMENT  OF  SCIENTIFIC  INFANT-FEEDING.         135 

Infants  Differ  in  Digestive  and  Assimilative  Efficiency. — It  has 
been  often  observed  that  some  infants  will  thrive  and  gain  in  weight 
on  an  amount  of  nutriment  that  others  of  the  same  age  fail  to  gain  on, 
and  that  some  infants  gain  in  weight  more  rapidly  on  the  same  quantity 
of  food  than  other  infants  do.  This  fact  has  been  perplexing  to  many, 
and  has  led  some  to  believe  there  was  no  science  in  infant-feeding,  each 
infant  being  a  law  unto  itself.  But  widely  extended  experiments  on 
animals  have  shown  that  they  differ  greatly  in  their  efficiency  in  appro- 
priating and  utilizing  food,  the  organs  of  assimilation  being  nearly 
twice  as  efficient  in  some  animals  as  in  others  of  the  same  species. 

Assimilation  Most  Efficient  in  Early  Infancy. — The  capacity  for 
assimilation  of  food  is  not  the  same  at  all  periods  of  growth.  It  is 
greatest  during  the  early  part  of  infancy  and  becomes  gradually  less 
as  maturity  is  approached,  until  no  matter  how  much  food  is  eaten 
only  the  normal  metabolic  loss  is  made  gopd,  and  fat  is  stored  up, 
any  excess  of  proteins  being  excreted.  Young  infants  have  been 
found  to  store  up  70  per  cent,  of  the  proteins  of  their  food,  and 
young  calves  have  also  been  found  to  convert  this  same  percentage 
of  proteins  into  tissue,  but  in  the  adult  as  much  nitrogen  as  is  taken  in 
as  protein  is  excreted,  so  none  is  fixed  as  new  tissue.  Therefore  a 
sufficient  quantity  of  tissue-building  food  (protein)  earhj  in  life  is  of 
the  greatest  importance  from  a  point  of  economical  use  of  food  and 
for  promoting  vigorous  growth.  In  producing  meat  for  market  this 
fact  is  taken  advantage  of  by  scientific  meat  producers  as  it  adds  to 
their  profits.  It  is  also  important  in  another  way,  for  at  this  period 
the  digestive  organs,  liver,  kidneys,  and  heart  are  developing  rapidly, 
and  the  size  and  strength  of  these  organs  will  depend  upon  the  supply 
of  building  material  available,  which  is  protein. 

There  have  been  those  who  did  not  take  into  consideration  the 
great  power  of  assimilation  during  early  infancy  who  have  advocated 
the  use  of  a  very  small  quantity  of  proteins  in  the  infant's  food  during 
the  first  few  months  of  life,  not  over  one-third  as  much  as  supplied  by 
the  mother,  to  avoid  digestive  troubles.  Of  course,  if  an  infant  has 
indigestion  its  food  should  be  reduced  to  its  digestive  capacity,  but 
no  greater  mistake  is  made  in  infant-feeding  than  to  keep  infants  on 
food  containing  a  small  quantity  of  protein  for  any  length  of  time,  for 
as  the  infant  becomes  older,  increasing  the  quantity  in  the  food  is  off- 
set by  the  lessened  capacity  of  assimilation.  Proper  feeding  in  the 
first  few  w^eeks-  or  months  after  birth  insures  good  development  and 
freedom  from  trouble  later  on.  If  an  infant  is  badly  fed  during  this 
formative  period,  its  management  later  on  may  be  a  tedious  and 
difficult  matter. 


CHAPTER  XVI. 
PRACTICAL  FEEDING. 

Basis  of  Practical  Feeding. — No  matter  how  much  the  actual 
processes  employed  in  preparing  food  for  infants  may  differ,  they 
all  have  for  their  object  the  combination  of  protein,  mineral  matter, 
fats,  carbohydrates,  and  water  in  some  form  that  will  be  acceptable  to 
the  infant.  It  has  been  shown  on  pages  110,  111  that  it  is  important 
for  these  ingredients  to  be  present  in  the  food  in  certain  relative 
proportions  if  the  infant  is  to  develop  properly,  and  with  the  least 
amount  of  waste  of  digestive  and  assimilative  effort.  It  is  likewise  of 
importance  to  understand  methods  of  calculating  the  quantities  of  the 
food  elements  in  any  food  mixture,  and  how  to  determine  the  quanti- 
ties of  milk,  cereals,  sugar,  and  other  materials  necessary  to  use  to 
produce  different  food  mixtures  containing  any  desired  quantities  of 
protein,  mineral  matter,  fats,  carbohydrates,  and  water.  The  best 
practice  is  to  think  of  the  percentage  composition  of  the  food,  and 
many  times  the  cause  of  digestive  disturbance  in  infants  can  be  deter- 
mined by  working  out  the  approximate  percentage  composition  of 
their  food  from  the  formula  used  in  making  it,  when  it  may  be  found 
that  one  or  more  ingredients — that  is  proteins,  fats,  or  carbohydrates — 
are  present  either  in  excess  or  in  too  small  quantity. 

Percentage  Milk  Mixtures  in  Infant-feeding. — As  was  stated  on 
page  115,  the  best  milk  to  use  in  feeding  infants  is  that  produced 
under  sanitary  conditions,  bottled  at  the  dairy  and  kept  iced  until 
delivered  to  the  family.  When  such  milk  is  delivered  the  cream  has 
risen  and  appears  as  a  distinct  layer  at  the  top  of  the  bottle.  If  the 
bottle  of  milk  is  shaken  to  mix  its  contents,  the  milk  will  then  have  a 
uniform  composition  which  will  almost  always  fall  between  the 
following  extremes: 

Protein  Mineral  matter  Fats  Carbohydrates 

3%-3.5%  .6%-.  8%  3%-5%  4%-6% 

To  make  simple  approximate  calculation  of  the  quantities  of  these 
elements  that  cow's  milk  imparts  to  a  mixture,  it  is  best  to  take  the 
mean  composition  of  commercial  cow's  milk  as  a  working  basis,  especi- 
ally as  a  large  part  of  the  bottled  milk  has  about  this  composition. 
If   milk  above  this  mean  is  used  the  error  cannot  be  great,   and   if 

136 


PRACTICAL  FEEDING.  137 

below  the  error  will  also  be  small.     For  this  reason  it  is  advisable  to 
take  as  a  working  basis  the  following  figures: 

Protein  Mineral  matter  Fats  Carbohydrates 

3.2%  .7%  4%  5% 

At  one  time  the  figures  proteins  4%,  fat  4%,  and  carbohydrates  4%  were  used 
but  as  the  error  in  proteins  was  about  25%  they  are  not  being  used  so  much. 
Some  take  the  protein  as  3.5%,  but  this  is  rather  high  for  the  general  run  of  milk- 

If  a  feeding  mixture  contains  one-fourth  milk,  the  quantities  of 
the  food  elements  supplied  by  the  milk  will  be  one-fourth  of  the 
foregoing  figures  or: 

Protein  Mineral  matter  Fats  Carbohydrates. 

4  [3 .2% .7% 4% 5% 

.80%  .18%  1%  1.25% 

If  the  proportion  of  milk  in  the  food  was  one-third,  one-half,  one- 
tenth,  or  any  other  fraction,  the  composition  of  the  food  would  be 
determined  in  the  same  manner. 

Top  Milk. — When  whole  milk  is  diluted  for  infant-feeding  the 
proportion  of  fat  in  the  diluted  milk  is  too  small  for  most  healthy 
infants,  as  is  also  the  quantity  of  sugar  or  carbohydrates,  so  it  is 
necessary  to  add  these  elements.  The  quantity  of  protein  in  cow's 
milk  is  too  great  for  most  infants  to  digest,  and  more  than  they  require 
for  growth,  and  therefore  it  is  to  reduce  the  quantity  of  proteins  that 
the  milk  is  diluted. 

Formerly  the  addition  of  cream  to  diluted  milk  was  a  favorite 
method  of  adding  fat,  as  it  is  essentially  milk  extra  rich  in  fat,  the 
protein  and  carbohydrates  being  present  in  but  slightly  less  quantities 
than  are  found  in  whole  milk.  However,  several  objectionable 
properties  of  cream  make  its  use  inadvisable.  First,  its  composition 
is  not  uniform,  and  then  it  may  be  old  and  heavily  laden  with  bacteria 
which  will  infect  any  sanitary  milk  it  may  be  mixed  with;  and,  again, 
it  may  have  been  passed  through  a  centrifuge,  and  had  its  natural 
emulsion  destroyed  (see  page  118),  so  that  it  becomes  more  oily.  In 
addition  to  these  material  objections,  it  is  a  difficult  matter  for  many 
to  calculate  the  composition  of  food  made  with  cream  and  milk,  and 
great  errors  in  the  composition  of  the  food  result  from  mistakes  in 
the  arithmetical  process,  the  infants  often  suffering  from  the  im- 
proper food. 

These  drawbacks  to  the  use  of  cream  have  caused  this  method 
of  adding  fat  to  the  infant's  food  mixture  to  be  largely  supplanted 
by  the  top-milk  method,  which  is  simple  and  exceedingly  accurate. 


138 


DISEASES  OF  CHILDREN. 


As  was  stated  above,  when  milk  is  bottled  and  kept  cool  the 
cream  rises  to  the  top  of  the  bottle  and  forms  a  distinct  layer.  .  This, 
cream  contains  nearly  all  of  the  fat  of  the  milk,  the  milk  under  the 
cream  layer  often  containing  only  0.4  per  cent,  of  fat,  while  the 
cream  at  certain  levels  may  contain  as  high  as  25  per  cent,  of  fat. 
The  layer  of  cream  is  not  uniform  in  composition,  as  will  be  seen  by  the 


nsnttniniwoFmMOT 

BOITLEOF^XMILK.EACH  OX, 
REMOVED  WITH  DIPPER 


LAYER  OF  CREAM 

NOT  UNIFORM  IN 
COMPOSITION 


lilOZ. 


FAT  IN  DIFFERENT  PORTIONS 

REMOVED  FROM  THE  TOP 

AND  MIXED. 


2Ng02.  TOP   2  OZS.  MIXED  24  ft  FAT 


35502. 


4tH0Z. 


SIbOZ. 


6TH0Z. 


7IH0Z. 


siaoz. 


9Ifl02. 

lOtHQZ. 


3  OZS. 

4  OZS. 
6  OZS. 

6  OZS. 

7  OZS. 

8  OZS. 

9  OZS. 
10  OZS. 


a 


12  OZS.  ' 

"     14  OZS.  ' 

"    16  OZS.  • 

"    18  OZS.  • 

"    20  OZS.  ' 

"   22  OZS.  ' 

"   24  OZS,  • 

"    26  OZS.  • 

"    28  OZS.  ' 

"    30  OZS.  ' 
ALL  MIXED 


22.55« " 
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19.2;*'* 
16.8;<" 

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B.8s<'* 

5.4)f" 

B.OJI'* 

4.7X  " 

4.5i^  " 

4.3}<" 

4.1  !<  " 


Fig.  41. — Percentages  of  fat  in  different  portions  of  a  quart  bottle  of  milk. 

illustration  of  the  amount  of  fat  in  each  ounce  removed  from  the  top 
of  a  quart  of  milk  containing  4  per  cent,  of  fat  even  on  which  the 
cream  had  not  completely  risen,  as  is  shown  by  the  high  percentage 
of  fat  in  the  milk  under  the  cream  layer. 

At  one  time  it  was  believed  that  cream  which  rose"  of  its  own 
accord,  and  known  as  gravity  cream,  was  uniform  and  contained  but 
16  per  cent,  of  fat;  and  as  very  often  the  cream  to  be  added  to  the 
infant's  food  was  taken  directly  from  the  mouth  of  a  quart  bottle, 


PRACTICAL  FEEDING.  139 

instead  of  the  infant  getting  16  per  cent,  fat  cream,  one  containing  25 
per  cent,  or  more  of  fat  was  obtained.  A  common  thing  at  one  time 
was  to  see  infants  suffering  from  fat  indigestion  caused  by  an  excess 
of  fat  thus  unwittingly  introduced  into  the  food. 

It  is  evident  that  if  all  of  the  fat  of  a  quart  of  whole  milk  contain- 
ing 4  per  cent,  of  fat  rose  to  the  surface,  the  top  or  upper  pint,  or  one- 
half  of  the  quart  of  milk,  would  contain  twice  the  percentage  of  fat  in 
the  original  milk,  or  8  per  cent.,  while  the  remaining  pint  would  contain 
no  fat  at  all.  If  all  of  the  fat  was  in  the  top  one-third  of  the  quart  of 
milk  it  would  contain  three  times  4  per  cent,  or  12  per  cent,  of  fat. 

As  a  matter  of  fact,  nearly  all  of  the  fat  in  a  quart  of  milk  is  found 
in  the  top  six  to  eight  ounces  after  the  cream  has  risen,  so  by  taking 
all  of  this  layer  of  cream  with  some  of  the  fat-free  milk  underneath, 
milk  containing  U,  2,  3,  or  any  other  number  of  times  as  great  a 
percentage  of  fat  as  the  whole  milk  contained  may  be  had  from  the 
ordinary  quart  bottle  of  milk.  As  a  small  percentage  of  fat  remains 
in  the  milk  below  the  cream,  a  little  less  than  the  above  theoretical 
quantities  are  removed  from  the  top  of  the  bqttle. 

These  top  milks,  as  they  are  called,  contain  about  the  same 
quantities  of  protein,  mineral  matter,  and  carbohydrates  as  whole 
milk,  so  when  using  whole  milk  or  top  milks  for  dilution  the  per- 
centages of  all  the  elements  except  the  fat  will  be  the  same  no  matter 
which  is  diluted.  Therefore,  by  using  definite  quantities  of  the  upper 
part  of  a  quart  of  milk  after  the  cream  has  risen  the  amount  of  fat 
in  the  diluted  milk  can  readily  be  varied,  while  the  percentages  of  the 
other  elements  remain  unchanged.  For  example,  there  could  be 
obtained  top  milks  containing 

Fat                            Carbohydrates  Protein 

6%  5%  3.2% 

7%  5%  3.2% 

8%  5%  3.2% 

10%  5%  3.2% 

12%  5%  3.2% 

16%  5%  3.2% 

And  if  each  was  diluted  four  times  the  diluted  milk  would  contain 
percentages  equal  to  one-fourth  of  these  figures,  or 

Fat                            Carbohydrates  Protein 

1.5%  1.25%  .80%, 

1.8%  1.25%  .80% 

2.0%  1.25%  .80% 

2.5%  1.25%  .80% 

3.0%  1.25%  .80% 

4.0%  1.25%  .80% 


140 


DISEASES  OF  CHILDREN. 


The  percentages  of  the  elements  in  any  dilution  can  readily  be  de- 
termined in  the  same  manner. 

To  obtain  these  different  top  milks  the  dipper"^  shown  in  Fig.  43 
is  used.     It  measures  one  ounce. 


Fig.  42. — Quart  bottle  of    milk, 
showing  layer  of  cream. 


Fig.  43.— 
Chapin  cream 
dipper. 


The  following  ke}^  by  Deming  shows  how  to  find  the  percentages 
of  the  food  elements  if  the  proportion  of  milk  or  top  milk  in  the  mix- 
ture is  known,  and  what  proportion  of  milk  or  top  milk  to  use  to  ob- 
tain any  desired  percentage  combinations  of  the  milk  elements. 

Percentage  Cereal  Gruels. — ^Until  comparatively  recently  the  use 
of  cereal  gruels  has  been  purely  empirical,  and  little  attention  has  been 
paid  to  their  composition  or  nutritive  value.  But  recognition  of 
the  benefits  to  be  derived  from  their  intelligent  employment  is  leading 
to  their  being  used  in  a  scientific  manner,  and  the  tendency  is  to  pre- 
scribe them  in  definite  quantities  and  of  approximately  definite  per- 
centage composition.  The  composition  of  cereal  gruels  depends 
upon  the  cereal  employed  in  making  them  and  also  to  a  much  greater 

lit  is  known  as  the  Chapin  Dipper  and  is  sold  through  the  wholesale  druggists. 
It  can  be  obtained  by  mail  of  Cereo  Company,  Tappan,  N.  Y.,  for  fifteen  cents, 
made  of  heavy  tinned  steel,  or  of  aluminum  for  twenty-five  cents;  also  from  Jas. 
T.  Dougherty,  411  West  Fifty-ninth  St.,  Xew  York. 


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PRACTICAL  FEEDING.  143 

extent  upon  the  condition  of  the  cereal,  that  is,  whether  it  is  in  the 
form  of  flour,  granulated,  or  in  the  whole  state.  If  flour  is  used  in 
making  the  gruel  and  none  is  removed  by  straining,  dividing  the  com- 
position of  the  flour  by  the  number  of  parts  of  gruel  made  from  one 
part  of  flour  will  give  its  composition;  as,  for  instance,  a  gruel  made 
with  one  ounce  of  flour  to  the  pint  would  be  one-sixteenth  as  strong 
as  the  flour.  But  when  whole  or  granulated  cereals  are  used,  a  large 
part  of  the  proteins  and  considerable  of  the  carbohydrates  are  removed 
by  straining,  as  the  cereal  does  not  disintegrate  while  cooking  and 
the  composition  of  the  gruel  is  not  in  proportion  to  the  composition 
of  the  cereal  employed. 

In  using  ordinary  cereals  in  preparing  gruels  the  following  quan- 
tities will  be  approximated,  when  a  tablespoon  is  used  in  measuring 
the  cereals. 

1  level  tablespoonful  of  pearl  barley  weighs  2  oz.  avoirdupois. 
1  level  tablespoonful  of  barley  flour  weighs  ^  oz.  avoirdupois. 
1  level  tablespoonful  of  wheat  flour  weighs  \  oz.  avoirdupois. 
1  level  tablespoonful  of  rolled  oats  weighs  I  oz.  avoirdupois. 

When  the  ordinary  cereals  are  made  into  gruels  they  will  have 
approximately  the  following  composition: 

If  all  of  the  rolled  oats  had  remained  in  the  gruel  made  wdth 
one  ounce  to  the  quart,  the  gruel  would  have  contained  about  0.50 
per  cent,  proteins,  as  these  rolled  oats  contained  about  16  per  cent, 
proteins,  but  the  gruel  actually  contained  but  0.26  per  cent,  proteins, 
showing  half  of  the  proteins  were  removed  when  the  gruel  was  strained. 

There  can  now  be  obtained  through  the  drug  stores  a  series  of 
standardized  flours  for  making  gruels  known  as  Cereo  Gruel  Flours, 
put  up  in  tins  the  covers  of  which  measure  one  ounce  of  flour.  On 
the  labels  is  given  the  quantity  of  flour  to  use  to  make  a  gruel  of  any 
desired  composition.  Gruels  made  from  these  flours  contain  more 
proteins  than  gruels  made  from  ordinary  cereals,  as  will  be  seen  by 
comparing  the  composition  of  gruels  in  Table  II  with  those  in  Table  I. 

Percentage  Composition  of  Milk  and  Gruel  Mixtures. — When  milk 
or  top  milk  is  mixed  with  gruel  the  percentage  of  fat  in  the  mixture  is 
not  affected  by  the  gruel,  as  gruels  contain  negligible  quantities  of 
fat,  but  the  percentages  of  protein  and  particularly  those  of  the  carbohy- 
drates, are  much  greater  than  when  milk  is  mixed  with  water.  The 
following  table  shows  the  amount  of  proteins  and  carbohydrates  in 
various  dilutions  of  milk  and  gruels  made  from  the  standardized  gruel 
flours  mentioned  above  are  used. 


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PRACTICAL  FEEDING.  145 

Illustrations  of  Use  of  Previous  Tables. — Wide  experience  has 
demonstrated  that  there  are  certain  percentages  of  each  of  the  food 
elements  more  than  which  it  is  not  safe  to  have  in  the  food  of  most  in- 
fants, and  other  percentages  less  than  which  the  food  should  not  con- 
tain as  it  will  not  be  sufficiently  nutritious. 

It  is  seldom  advisable  to  have  the  food  of  infants  contain  over 
5  per  cent,  of  fat,  8  per  cent,  of  carbohydrates,  or  3.5  per  cent,  of  pro- 
teins. The  mineral  matter  in  mixtures  is  generally  sufficient,  and  as 
yet  no  attempt  has  been  made  to  deal  with  the  complex  substances 
that  make  up  this  element  of  the  food. 

For  the  great  majority  of  infants  the  maximum  percentages  just 
mentioned  should  not  be  employed  as  they  will  cause  disturbances, 
and  it  is  only  after  a  period  in  which  the  strength  of  the  food  is  grad- 
ually increased  that  high  percentages  can  be  tolerated  by  any  infants. 
However,  many  times  infants  are  given  as  great  or  greater  percent- 
ages inadvertantly  by  those  who  do  not  estimate  the  composition  of 
the  feeding  mixture,  and  a  great  deal  of  unnecessary  disturbance 
results. 

For  instance,  an  infant  is  given  a  mixture  composed  of  the  top  nine  ounces 
from  one  quart  of  milk,  nine  ounces  of  water,  and  one  ounce  of  sugar.  It  vomits 
a  great  deal  and  is  not  doing  well.  By  reference  to  the  key  to  composition  of  milk 
mixtures  on  page  141  it  will  be  found  that  a  mixture  containing  one-half  top  milk 
made  by  using  the  top  nine  ounces  from  a  quart  bottle  and  one-half  water  will 
contain  6  per  cent,  fat,  1 . 6  per  cent,  protein,  and  about  1 .6  per  cent,  carbohydrates. 
The  one  ounce  of  sugar  added  would  be  a  trifle  over  one-twentieth  of  the  mixture, 
or  5  per  cent.,  which  would  bring  the  percentage  in  the  mixture  up  to  over  7  per 
cent.  The  mixture  would  be  looked  upon  as  being  composed  of  fat  6  per  cent., 
carbohydrates  7  per  cent.,  and  protein  1.6  per  cent.  As  vomiting  is  often  caused 
by  too  much  fat  in  the  food,  the  inference  would  be  that  as  the  percentage  of  fat 
was  above  that  found  to  agree  with  most  infants  it  should  be  cut  down.  A 
glance  at  the  key  shows  that  if  the  top  twenty  ounces  is  removed  from  the  bottle 
and  mixed  to  make  its  composition  uniform  and  is  then  diluted  in  the  same  pro- 
portion, that  is,  equal  parts  of  the  top  milk  and  water,  the  percentage  of  fat  in  the 
mixture  will  be  3  per  cent.,  which  would  be  about  what  would  be  suitable  for 
most  infants.  If  this  top  milk  was  substituted  for  the  top  nine  ounces  and  the 
infant  had  no  more  difficulty  with  its  food,  it  would  be  conclusive  that  an  excess 
of  fat  caused  the  trouble,  especially  if  the  stools  were  sour-smelling  and  frothy- 

Another  infant  might  be  seen  who  had  sour,  watery  movements  that  irritated 
the  skin.  Its  food  might  have  been  made  as  follows:  Whole  milk,  eight  ounces; 
wheat-flour  gruel  (two  ounces  flour  to  quart),  eight  ounces;  granulated  sugar, 
two  level  tablespoonfuls;  total,  sixteen  ounces.  Referring  to  the  table  on  page  144, 
showing  the  composition  of  milk  and  gruel  mixtures,  it  is  found  that  a  mixture 
half  milk  and  gruel  (two  ounces  flour  to  quart)  contains  2  per  cent,  protein  and 
4.9  per  cent,  carbohydrates.  From  the  key  on  page  141  it  is  found  that  two 
level  tablespoonfuls  of  granulated  sugar  weigh  one  ounce,  which  would  be  one- 
10 


146  DISEASES  OF  CHILDREN. 

sixteenth  of  the  mixture  or  slightly  over  6  per  cent.  Thus,  to  a  mixture  containing 
4.9  per  cent,  carbohydrates  there  is  added  6  per  cent,  more,  making  a  total  of 
practically  11  per  cent,  carbohydrates  in  the  food.  Few  infants  can  digest  and 
assimilate  much  over  7  per  cent,  to  good  advantage,  and  the  indications  are  that 
in  this  case  the  excess  fermented  and  produced  acid  discharges.  One-half  a  level 
tablespoonful  of  the  sugar,  1^  per  cent.,  is  about  all  that  should]  have  been  added, 
as  this  would  have  made  the  total  about  7  per  cent. 

In  the  case  of  a  very  young  infant  suffering  from  colic,  and  with  curds  in  the 
stools,  a  mixture  containing  three  parts  of  milk  to  one  part  of  water  might  have 
been  given.  Referring  to  key  on  page  141,  it  will  be  found  that  a  mixture  con- 
taining three-fourths  milk  will  contain  2 . 4  per  cent,  protein,  from  which  the  curds 
are  formed.  Experience  has  shown  that  young  infants  should  not  at  first  have 
over  1  per  cent,  of  proteins  in  their  food,  as  their  digestive  organs  are  not  suflB- 
ciently  trained  to  digest  more  than  this  quantity,  when  not  in  the  form  of  protein 
of  breast-milk. 

If  the  proportion  of  milk  was  made  one-fourth  instead  of  three-fourths,  in  all 
probability  the  colic  would  disappear,  as  would  also  the  curds  in  the  stools.  Of 
course  sugar  would  have  to  be  added  to  milk  so  highly  diluted  to  save  the  infant 
from  living  on  its  own  tissues.  About  one  part  of  sugar  to  sixteen  parts  of  food 
would  be  required. 

There  was  a  time  when  it  was  firmly  believed  by  many  that  all  of 
the  digestive  disturbances  of  infancy  could  be  successfully  treated  by 
thus  altering  the  percentage  composition  of  the  food,  but  it  is  now 
known  that  other  factors  are  involved,  and  that  while  adjustment  of 
percentage  composition  is  an  important  matter,  still  there  are  other 
points  equally  important  to  be  taken  into  consideration. 

It  is  only  a  waste  of  time  and  energy  for  the  physician  to  commit 
to  memory  lists  of  percentages  suitable  for  different  ages  and  con- 
ditions. If  he  will  study  each  case  as  it  presents  itself  and  work  out 
the  composition  of  each  food  that  is  disagreeing,  he  will  soon  come  to 
understand  what  percentages  to  use  to  get  best  results,  and  also  to  know 
what  other  methods  besides  changing  percentages  to  employ  under 
different  conditions. 

Outline  of  Feeding  Directions. — It  is  impossible  to  give  explicit 
directions  for  preparing  food  for  each  particular  infant,  as  infants 
differ  in  their  digestive  capacity  and  in  their  efficiency  in  assimilating 
food,  as  mentioned  on  page  135,  and  in  their  condition  when  the  physi- 
cian is  called  in.  However,  all  cases  naturally  fall  under  about  four 
headings:  (a)  Well  infants  which  cannot  obtain  breast-milk,  and 
the  control  of  which  the  physician  has  from  the  start.  -  (6)  Infants 
that  are  well  except  that  they  are  suffering  from  bad  methods  of  feed- 
ing, (c)  Infants  of  feeble  constitution  whose  digestion  is  easily 
deranged,     (d)    Infants  that   are  acutely  ill.      Before  attempting  to 


PRACTICAL  FEEDING.  147 

feed  an  infant,  its  feeding  history  should  be  carefully  taken  to  deter- 
mine in  which  class  the  infant  belongs. 

The  methods  of  feeding  these  different  classes  of  infants  vary 
considerably,  and  while  the  same  general  principles  hold,  they  must  be 
applied  differently.  In  all  methods  attention  must  be  paid  to  per- 
centage composition  of  the  food.  This  is  not  a  difficult  matter,  and 
can  be  readily  learned,  but  the  skill  and  ability  of  the  infant  feeder 
have  a  chance  for  display  when  it  comes  to  adapting  the  form  of  the 
protein,  fats,  and  carbohydrates  to  the  infant;  or  to  modifying  the 
action  of  the  infant's  digestive  secretions  on  its  food  by  various 
additions  to  the  food  as  explained  on  page  130.  In  the  suggestive 
feeding  mixtures  given  here  the  preparation  of  the  food  is  sharply 
divided  into  two  parts:  First,  adjustment  of  the  quantitative  or 
percentage  composition.  Second,  modification  of  the  form  of  the  food, 
or  the  action  of  the  digestive  secretions  on  the  food. 

Food  for  Healthy  Infants. 

The  object  in  preparing  food  for  healthy  infants  is  to  so  modify  or 
adapt  the  food  that  they  will  be  well  nourished  and  have  their  digestive 
organs  so  developed  that  the  infants  will  become  able  to  take  whole 
cow's  milk  without  digestive  disturbance.  It  is  generally  about  the 
ninth  to  twelfth  month  before  this  is  possible,  and  if  alkalies  or  antacids 
have  been  added  to  the  food  in  too  great  quantities  it  may  be  later, 
as  these  substances  seem  to  interfere  with  the  normal  development 
of  the  stomach. 

In  reality  the  whole  process  amounts  to  a  training  of  the  infant's 
digestive  organs,  and  it  is  important  to  commence  in  the  early  months 
with  small  quantities  of  the  protein  of  cow's  milk,  as  this  causes  the 
greatest  amount  of  trouble,  moderate  quantities  of  fat,  and  a  liberal 
supply  of  carbohydrates,  as  these  cause  little  digestive  disturbance 
when  not  given  in  too  great  excess.  The  fats  are  kept  in  the  neighbor- 
hood of  3  per  cent,  during  the  whole  period  of  artificial  feeding,  and  the 
carbohydrates  at  about  6  per  cent,  or  7  per  cent.,  seldom  over  these 
figures.  But  the  protein  is  managed  in  an  entirely  different  manner. 
At  first  the  protein  is  given  in  as  small  a  quantity  as  0.4  per  cent., 
or  about  one-eighth  as  much  as  is  found  in  cow's  milk,  and  about 
one-fourth  as  much  as  in  breast  milk.  As  soon  as  a  tolerance  is 
established  the  quantity  is  increased  about  0.40  per  cent,  'at  a  time 
until  the  infant  is  able  to  digest  whole  milk  with  its  3.20  per  cent, 
of  protein.  These  advances  in  strength  of  food  are  made  about  a 
month  apart.     There  is  no  fixed  rule,  except  to  increase  as  rapidly  as 


148 


DISEASES  OF  CHILDREN. 


the  infant  can  stand  it.  With 
some  the  advance  can  be  quite 
rapid,  while  with  others  it  must 
be  made  slowly. 

By  this  process  the  heat 
and  energy  portions  of  the  food 
are  kept  up  to  the  highest  point 
of  efficiency,  while  the  growth- 
producing  elements  are  at  first 
given  in  less  quantities  than  is 
desirable;  but  gradually  they 
are  brought  up  to  a  point  where 
proper  tissue  formation  becomes 
possible.  If  the  protein  is  given 
in  too  great  quantities  at  first, 
indigestion  results  and  a  period 
of  greater  or  less  duration  ensueS' 
in  which  little  growth  can  be 
made.  For  this  reason  it  is 
better  in  the  long  run  to  slightly 
underfeed  with  protein  for  a 
short  time  and  avoid  digestive 
disturbances.  In  increasing  the 
quantity  of  protein  in  the  food 
it  is  often  the  case  that  the  more 
the  haste  the  less  the  speed. 

The  following  table  gives  an 
outline  of  the  quantities  and 
composition  of  food  which  may 
be  taken  as  a  working  basis  in 
preparing  food  for  healthy 
infants : 

The  whole  process  of  pre- 
paring the  food  is  shown  in  an 
extract  from  pictorial  directions 
for  preparing  food  devised  by 
Deming  (Fig.  44).  For  those 
whose  minds  do  not  run  to 
mathematics  a  percentage  milk 
modifier  will  be  helpful.  This 
is  a  measuring  glass  graduated  to  percentages  of  protein  and  fat  of 
cow's  milk.     Protein  may  be  varied  by  0.20  per  cent,  at  a  time  and 


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150 


DISEASES  OF  CHILDREN. 


fat  in  small  fractions  of  1  per  cent.  In  using  it,  milk  or  top  milk  is 
poured  into  the  graduate  up  to  the  figures  indicating  the  desired  per- 
centages of  protein  and  fat  and  the  glass  is  then  filled  with  a  diluent. 
The  percentage  of  fat  obtained  with  each  percentage  of  protein  when 
whole  milk  or  top  milk  is  used  is  shown  on  the  glass  at  the  same 
height  as  the  percentage  of  protein  (Fig.  45).  By  using  it  a  few  times 
the  physician  will  quickly  grasp  the  subject  of  percentage  mixtures. 

The  modifier  is  used  with  a  pic- 
torial prescription  blank  similar  to  Fig. 
44  which  the  physician  fills  out  and 
turns  over  to  the  mother  or  nurse.  It 
is  easy  to  use  in  practice  and  does  not 
necessitate  any  figuring. 

It  will  be  noticed  in  the  feeding 
table  that  less  sugar  is  to  be  added  to 
the  food  when  gruel  is  used  than  when 
water  diluent  is  employed.  This  is 
because  the  gruel  contains  consider- 
able carbohydrates.  The  quantities 
added  by  gruels  will  be  found  in  the 
table  on  page  144.  A  convenient  rule 
to  remember  is,  when  gruels  made 
with  one  ounce  of  flour  to  the  quart 
are  used,  add  3  per  cent,  of  sugar;  and 
when  two  ounces  of  flour  to  the  quart 
are  employed,  add  2  per  cent,  of  sugar. 
These  additions  would  be  one  thirty- 
third  and  one-fiftieth  of  the  total  quantity  of  the  food,  respectively.. 
These  proportions  will  always  make  the  percentage  of  carbohydrates 
in  the  food  between  6  and  8  per  cent. 

A  rule  often  employed  for  adding  sugar  to  food  is,  add  5  per  cent, 
or  one  part  to  twenty  parts  of  food.  TTiis  will  always  make  the 
percentage  of  carbohydrates  fall  between  5.5  per  cent,  and  9.5  per 
cent,  when  water  diluent  is  used  and  much  higher  when  gruel  diluent 
is  employed.  One  part  of  sugar  to  twenty-five  parts  of  food  makes 
the  percentage  of  carbohydrates  fall  between  5  per  cent,  and  8  per  cent, 
when  water  diluent  is  used. 

When  gruels  are  used  to  dilute  the  milk  the  percentages  of  protein 
in  the  mixtures  will  be  greater  than  those  given  in  the  feeding  table 
which  are  for  milk  and  water  mixtures.  By  referring  to  the  table  on 
page  144  it  will  be  found  that  a  mixture  made  with  milk  and  the  gruel 
given  above  (one  ounce  flour  to  quart)  will  contain  0.82  per  cent,  protein, 


Fig.  45. — Deming's  percentage 
milk  modifier. 


PRACTICAL  FEEDING.  151 

which  when  made  with  milk  and  water  would  contain  only  0.40  per 
cent,  protein.  The  mixture  containing  0.80  protein  would  contain 
1.16  per  cent,  if  the  gruel  was  employed,  the  1.2  per  cent,  mixture 
would  contain  1.5  per  cent.,  and  the  one  containing  1.6  per  cent,  w^ould 
be  increased  to  1.8  per  cent,  protein  if  the  gruel  was  used.  The  pro- 
tein thus  added  by  the  gruel  not  only  increases  the  tissue-building 
value  of  the  mixtures,  but  acts  as  a  mechanical  diluent  or  softener  of 
the  solid  formed  from  the  protein  of  the  cow's  milk,  and  hence  makes  it 
more  digestible.  As  the  value  of  gruels  when  used  intelligently  has 
become  better  appreciated,  they  have  come  to  be  employed  more  and 
more,  and  whenever  they  are  tolerated  they  should  be  used  in  preference 
to  water  for  diluting  the  milk.  Two  kinds  of  gruels  are  employed: 
(a)  those  made  by  boiling  the  cereal  in  water,  which  contain  starch  in  an 
unchanged  condition;  (b)  those  to  which  an  agent  for  changing  the  starch 
into  dextrin  and  maltose  is  added.  Gruels  so  made  are  called,  respec- 
tively, plain  gruels  and  dextrinized  gruels.  Dextrinized  gruels  should 
be  used  for  young  infants  and  when  plain  gruels  are  not  well  borne. 

Directions  for  Making  Gruels. — Stir  from  one  to  four  level  table- 
spoonfuls  of  the  cereal  flour  (p.  142)  into  one  quart  of  cold  water  to  avoid 
the  formation  of  lumps.  Place  the  mixed  flour  and  water  into  a  double 
boiler  (Fig.  46)  and  with  constant  stirring  bring  to  a  boil.     This  will 


Fig.  46. — Double  boiler 

cause  the  flour  to  swell  up  owing  to  the  gelatinization  of  the  starch. 
Now  allow  the  gruel  to  boil  for  fifteen  minutes.  Stirring  will  not  be 
necessary.  If  an  open  kettle  is  used  the  gruel  may  burn  at  the  bottom 
and  impart  a  bad  taste  to  the  food.  If  the  gruel  is  to  be  used  plain, 
strain  through  a  fine  wire  strainer  and  add  enough  boiled  water  to 
make  one  quart  of  gruel.  If  it  is  to  be  dextrinized  set  the  cooker  into 
cold  water  for  two  or  three  minutes  and  when  the  gruel  is  cool  enough 
to  taste  add  a  teaspoonful  of  some  preparation  of  diastase.  A  de- 
coction of  diastase  may  be  made  at  home  by  covering  a  tablespoonful 
of  crushed  malted  barley  grains  by  a  little  cold  water  and  placing  the 
mixture  in  the  refrigerator  over  night.     In  the  morning  the  water  that 


152  DISK\.SES  OF  CHILDREN. 

is  strained  ofif  will  be  active  in  diastase,  but  will  not  keep  long.  A 
glycerite  of  diastase  known  as  Cereo  is  now  made  for  this  purpose,  and 
has  proven  to  be  reliable.  Stir  and  the  gruel  will  become  thinner  as 
the  starch  goes  into  solution  and  forms  dextrin  and  sugar.  Strain 
and  add  enough  boiled  water  to  make  one  quart  of  gruel.  The  floccu- 
lent  matter  in  the  gruel  is  mostly  protein.  No  matter  which  kind  of 
gruel  is  employed  it  should  be  cooled  and  kept  on  ice  until  ready  to  be 
mixed  with  the  milk. 

Adaptation  of  Food  to  Infant. — So  far  the  directions  have  had  to 
do  only  with  bringing  together  the  food  elements  in  quantities  capable 
of  producing  proper  growth  and  development  at  different  ages.  But 
this  is  a  small  part  of  practical  infant-feeding,  for  any  one  of  the  fore- 
going mixtures  may  not  agree  with  the  infant.  The  problem  then 
becomes  how  to  adapt  the  food  so  that  it  will  agree  with  the  particular 
infant.  Adaptation  may  be  accomplished  in  a  number  of  ways, 
as  follows,  beginning  with  simple  changes  in  the  food  and  ending  in 
methods  that  are  more  complex  in  their  effects : 

Symptoms. — The  infant  has  no  digestive  disturbances,  except  slight  con- 
stipation and  scanty  stools,  but  does  not  gain  in  weight. 

What  to  Do. — Increase  the  strength  of  the  food  by  using  the  next  higher 
formula. 

Symptoms. — The  infant  vomits,  some  time  after  taking  its  food,  rancid- 
smelling  material ;  its  stools  are  soft  and  contain  small  flecks  or  white  particles. 

What  to  Do. — Reduce  the  amount  of  fat  in  the  food  by  using  weaker  top  milk 
or  plain  milk  in  making  the  food.  In  extreme  cases  use  skimmed  milk  in  making 
the  mixture  and  add  a  pinch  of  bicarbonate  of  sodium  to  each  feeding. 

Symptoms. — The  infant's  stools  are  inclined  to  be  too  soft,  but  otherwise  it 
seems  to  be  doing  well. 

What  to  Do. — Use  barley  or  wheat  in  making  gruels,  and  if  necessary  use 
weaker  top  milk  to  reduce  fat,  which  may  be  excessive. 

Symptoms. — The  infant  is  doing  well  with  the  exception  of  being  more  or 
less  constipated. 

What  to  Do. — Use  oat  gruel  for  diluting  the  milk  as  it  has  a  laxative  effect, 
and  increase  the  fat  in  the  food  to  3.5  per  cent  to  4  per  cent,  by  using  richer 
top  milk.     Give  boiled  water  between  feedings. 

Symptoms. — The  infant  suffers  from  colic,  but  has  no  curds  in  the  stools. 

What  to  Do. — Change  the  form  of  cereal  gruel  employed,  and  dextrinize,  if 
plain  gruel  has  been  used.  That  is,  if  oat  gruel  has  been  used,  try  barley  or  wheat 
gruel  which  has  been  dextrinized  in  its  place.     Pasteurize  the  food  temporarily. 

Symptoms. — The  infant  has  colic  with  more  or  less  curdy  stools. 

What  to  Do. — -If  water  has  been  used  in  making  the  food  mixture,  try  plain 
or  dextrinized  barley  or  wheat  gruel  instead  and  pasteurize  temporarily.  If 
this  does  not  overcome  the  difficulty,  add  one  to  two  tablespoonfuls  of  lime-water 
to  each  feeding  bottle;  or  add  one  to  three  grains  of  citrate  of  sodium;  or  add  two 
to  ten  grains  of  bicarbonate  of  sodium  to  each  feeding  bottle.  The  effect  of  these 
additions  will  be  found  at  page  130.  The  citrate  of  sodium  or  bicarbonate  of 
sodium  should  not  be  added  for  long  periods,  as  they  interfere  with  normal  di- 
gestive development. 

Symptoms. — The  infant  has  sour,  watery  stools. 


PRACTICAL  FEEDING.  153 

What  to  Do. — Reduce  the  quantity  of  sugar  in  the  food,  as  it  is  fermenting, 
and  also  change  the  form  in  which  it  is  given.  If  granulated  sugar  is  being  used, 
try  milk-sugar.  If  dextrinized  gruels  are  being  employed  try  plain  gruels.  Pas- 
teurize.    In  any  event  change  the  form  of  the  carbohydrates. 

Food  for  Infants  Previously  Badly  Fed. 

Feeding  History. — These  cases  almost  invariably  have  a  history 
of  being  well  nourished  at  birth,  and  perhaps  of  doing  well  at  the  breast 
until  for  some  reason  substitute  feeding  became  necessary,  when  con- 
taminated milk,  improper  modifications  of  milk,  or  proprietary  infant 
foods  were  tried  at  random,  and  many  or  few  changes  in  the  food  were 
made  as  method  after  method  failed.  These  infants  may  not  have  gained 
in  weight,  or  if  they  have  gained  in  weight  the  flesh  produced  has  been 
fatty,  caused  by  high  carbohydrates  in  the  food  with  low  protein. 
They  may  be  suffering  from  incipient  rickets,  or  show  signs  of  scurvy, 
and  in  severe  protracted  cases  may  have  drifted  into  marasmus. 
Man}'  cases  not  so  severe  simply  show  a  loss  of  weight  with  the  infants 
in  a  fair  condition. 

Management. — When  seen  early  this  is  the  simplest  class  of  cases 
the  physician  is  called  upon  to  treat  dietetically,  and  wdth  careful 
management  they  promptly  respond  to  treatment,  but  when  the  bad 
feeding  has  been  prolonged  the  cases  are  often  difficult  and  tedious. 
One  of  the  greatest  aids  is  to  work  out  the  composition  of  food  pre- 
viousl}^  given,  and  to  consider  the  methods  of  adapting  the  food  that 
may  have  been  used,  such  as  addition  of  lime-water,  bicarbonate  of 
sodium,  citrate  of  sodium,  etc.  It  is  of  material  assistance  to  know 
what  has  failed  and  whether  failure  followed  a  method  properly 
carried  out  or  whether  it  followed  incorrect  application  of  correct 
principles.  In  this  connection  it  may  be  stated  again  that  the 
physician  should  understand  every  detail  of  the  preparation  of  food 
by  all  methods,  be  able  to  make  gruels,  should  know  the  physical 
properties  of  food  prepared  in  different  ways,  and  also  be  acquainted 
with  their  taste  and  flavor.  Barley  gruel  has  a  slightly  bitter  taste, 
oat  gruel  has  a  distinctive  flavor,  as  has  also  legume  and  wheat  gruel. 
A  gruel  that  has  been  cooked  in  a  stew  pan  often  has  a  scorched  taste 
which  is  sometimes  very  repulsive.  The  food  may  have  been  kept 
in  a  warm  place  or  in  a  poor  refrigerator,  or  the  milk  may  have  been 
stale  or  it  may  have  been  partially  soured.  Occasionally  it  may  be 
found  the  proper  top  milk  is  not  being  used.  These  are  a  few  sug- 
gestions which  show  no  detail  of  preparing  the  food  should  be  over- 
looked or  vmknown  to  the  physician. 

For  mild  cases  putting  the  infant  on  a  formula  similar  to  one 
given  on  page  149  for  healthy  infants  of  the  same  age  will  be  all  that 


154  DISEASES  OF  CHILDREN. 

is  necessary,  although  a  very  good  plan  to  follow  is  to  give  the  food 
for  a  younger  infant  for  a  few  days  and  if  it  agrees  a  stronger  formula 
may  then  be  ordered. 

In  more  troublesome  cases  the  digestive  organs  must  be  given 
a  rest,  either  complete  or  partial;  that  is,  no  food  at  all  must  be 
given  for  a  few  hours,  or  the  infant  must  be  given  not  much  more 
than  enough  food  to  keep  it  from  living  on  its  own  tissues. 

The  following  food  mixtures  may  be  tried,  using  whichever  agrees 
best  or  can  be  prepared  to  best  advantage,  taking  into  consideration  the 
probabilities  of  directions  being  carried  out  properly. 

Dextrinized  barley,  legume,  oat  or  wheat  gruel,  made  with  one  to 
two  ounces  of  flour  (four  or  eight  level  tablespoonfuls)  to  the  quart 
of  gruel,  directions  for  preparing  which  will  be  found  on  page  151,  or 
whey  made  as  follows  may  be  used: 

Directions  for  Making  Whey. — From  a  quart  of  milk  remove  all 
of  the  cream.  Then  add  to  the  skimmed  milk  a  tablespoonful  of 
liquid  rennet  or  one  junket  tablet  such  as  may  be  had  at  grocery 
stores.  Place  the  milk  in  a  double  boiler  (see  page  151),  and  warm 
slowly.  When  the  milk  has  solidified  or  "set"  cut  it  in  all  directions 
into  small  pieces  to  allow  the  whey  to  escape.  Now  warm  up  to  about 
150°  F.,  and  stir  while  doing  so.  The  curd  which  was  all  broken  up 
will  cohere  into  one  or  more  large  pieces  which  may  readily  be  re- 
moved, and  about  twenty  ounces  of  clear  whey  will  remain.  If  the 
whey  is  heated  above  160°  F.  the  albumin  will  coagulate.  The  whey 
should  now  be  cooled  and  kept  on  ice  until  ready  to  be  fed.  Its 
composition  will  be  about,  protein  0.80  per  cent.,  fat  0.30  per  cent., 
carbohydrates  5  per  cent. 

Whey  and  Cream  Mixtures. — In  some  cases  mixtures  of  whey  and 
cream  are  tolerated  better  than  other  forms  of  food.  They  may  be 
conveniently  made  as  follows: 

From  one  quart  bottle  of  fresh  milk  remove  with  the  dipper  the  top 
6  ounces.  Place  the  remaining  26  ounces  in  a  double  boiler,  add  a  tea- 
spoonful  of  liquid  rennet  and  warm  slowly.  When  the  curd  has  become 
firm,  cut  it  into  small  pieces  with  a  knife  and  slowly  bring  to  150°  F. 
Strain  through  a  fine  wire  strainer,  or  cheese-cloth,  and  cool  the  whey. 

By  combining  the  whey  and  the  top  6  ounces  removed  from  the 
quart  milk  bottle  a  great  variety  of  mixtures  may  be  obtained  as  follows : 


Use  of  the  whey. 

Approximate-  Composition 

Use  of  the  top  6  ozs. 

Protein  j    Fat      Carbohydrates 

1  oz. 

2  ozs. 

3  ozs. 

15  ozs. 
14  ozs. 
13  ozs. 

.80%      1    %              5% 
1.00%      2.5%              5% 
1.20%  i  3.3%  1           5% 

PRACTICAL  FEEDING.  155 

The  quantities  to  be  given  are  a  little  less  than  the  amount  of  food 
that  would  be  appropriate  for  a  well  infant  of  the  same  age.  If  any  of 
these  foods  are  well  borne,  milk  may  be  added,  a  teaspoonful  to  a 
feeding,  to  see  if  it  will  be  tolerated,  and  if  so  a  weak  milk  mixture 
may  be  given  and  the  strength  of  the  food  increased  by  degrees  until 
full  strength  for  the  age  is  reached.  If  rickets  or  scurvy  is  present, 
more  care  in  treatment  will  be  necessary,  and  this  must  be  according 
to  lines  laid  down  under  these  titles. 

Food  for  Infants  of  Feeble  Constitution. 

This  is  one  of  the  most  difficult  classes  of  infants  the  physician 
has  to  feed,  and  they  often  tax  his  ingenuity  to  the  utmost.  They 
are  generally  the  offspring  of  nervous  parents  and  are  easily  thrown 
out  of  equilibrium.  They  catch  cold  easily  and  are  subject  to  attacks 
of  indigestion  from  trivial  causes.  During  the  warmer  months  they 
are  readily  attacked  by  gastroenteritis,  and  their  management  then 
becomes  tedious  and  their  progress  is  slow,  careful  watching  of  the 
feeding  being  necessary  at  all  times. 

Whenever  possible  a  wet-nurse  should  be  obtained  for  these 
cases.  Artificial  feeding  is  unnatural  in  all  cases,  and  while  it  may 
succeed  in  a  majority  of  instances,  its  success  is  due  not  so  much  to 
the  superior  character  of  the  food  as  to  the  infant's  ability  to  adapt 
itself  to  its  new  food.  This  power  of  adapting  to  environment  is 
feeble  in  these  infants  of  unstable  constitution,  and  too  much  depend- 
ence should  not  be  placed  upon  it.  Valuable  time  and  strength 
should  not  be  wasted  in  attempts  at  finding  a  food  that  will  agree  with 
the  infant  when  it  is  possible  to  secure  a  wet-nurse.  At  this  point  it 
will  be  well  to  refer  to  page  90  where  the  natural  place  of  breast- 
feeding will  be  impressed  upon  the  mind. 

A  Wet-nurse  Unobtainable. — When  the  services  of  a  suitable  wet- 
nurse  cannot  be  had,  substitute  feeding  must  be  tried,  and  methods 
that  at  one  time  would  have  been  looked  upon  as  quite  unscientific 
are  the  ones  most  likely  to  give  good  results.  One  should  not  approach 
these  cases  with  fixed  ideas  of  what  they  ought  to  take  and  keep  on 
with  food  that  is  evidently  disagreeing.  All  of  the  infants  must  have 
protein,  mineral  matter,  fats,  carbohydrates,  and  water,  and  in  this 
class  of  cases  it  is  perfectly  justifiable  to  supply  them  in  any  form  that 
is  acceptable  to  the  infant.  Of  course,  this  statement  is  not  to  be  con- 
strued as  meaning  any  nostrum  that  may  be  suggested  should  be 
tried,  but  a  combination  of  the  food  elements  that  is  quite  unlike 
either  human  milk  or  cow's  milk  in  general  composition  or  physical 
properties,  such  as  given  on  page  156  may  be  offered.     The  point  to 


156  DISEASES  OF  CHILDREN. 

bear  in  mind  in  the  management  of  these  cases  is  to  keep  the  infants 
alive  and  as  rapidly  as  possible  build  up  their  strength,  and  when 
this  is  done  place  them  on  a  more  natural  diet. 

There  is  more  to  feeding  than  combining  food  elements  in 
certain  more  or  less  definite  proportions.  A  subtle  factor  in  manag- 
ing these  difficult  cases  is  the  arousing  of  the  dormant  powers  of  diges- 
tion and  assimilation  of  the  infants.  This  is  often  accomplished  by  a 
change  in  the  flavor,  taste,  or  physical  condition  of  the  food  and  in  the 
form  in  which  some  of  the  elements  are  supplied.  So  simple  a  change 
as  substituting  dextrinized  gruel  for  plain  gruel  of  the  same  strength, 
in  a  modified  milk  mixture,  has  changed  an  infant  which  had  worn  out 
a  family  with  its  digestive  troubles  into  a  well-satisfied,  contented  baby 
in  one  day.  The  use  of  cooked  foods,  broths,  or  other  forms  of  food, 
such  as  egg  mixtures  or  legume  gruels,  has  also  brought  about  sudden 
and  permanent  improvement.  Chemical  analysis  does  not  show 
what  there  is  about  the  food  that  produces  such  changes  in  digestion 
and  assimilation,  but  that  different  forms  of  food  do  have  different 
effects  on  different  individuals  is  an  undeniable  fact,  well  known  to 
animal  feeders,  who  find  that  by  catering  to  the  idiosyncrasies  of  indi- 
vidual animals,  much  better  assimilation  is  brought  about,  and  more 
economical  use  is  made  of  the  food.  This  comes  under  the  head,  or 
in  the  same  class,  as  the  fact  that  food  served  to  an  adult  in  an 
attractive,  appetizing  manner  will  be  digested  much  better  than  if 
it  is  served  in  an  unattractive,  repulsive  condition. 

Food  for  the  Acutely  111. 

Classification  of  Cases. — Under  the  heading  of  Acutely  111  it  is 
intended  to  group  only  those  whose  illness  is  reflected  in  disturbances 
of  the  digestive  organs  or  by  general  malnutrition.  Infants  may 
be  acutely  ill  with  pneumonia  or  other  infections  and  still  not  show 
special  derangement  of  the  nutritional  functions.  Again,  as  in  gastro- 
enteritis, there  is  an  infection  or  intoxication  which  calls  for  more  than 
dietetic  treatment,  so  such  cases  will  be  treated  under  their  respective 
titles. 

Management  of  Cases. — In  all  of  these  cases  it  is  of  first  impor- 
tance to  find  something  that  will  be  retained,  and  before  time  is  wasted 
in  calculating  a  theoretically  indicated  mixture  which  may  be  re- 
jected, it  will  be  best  to  try  some  of  the  following  mixtures,  which 
if  retained,  will  serve  as  a  starting-point  in  working  up  to  ■&  suitable 
food  mixture. 

1.  Dextrixized  barley,  legume,  oat  or  wheat  gruel  made 
with  one  ounce  of  flour  to  the  quart,  as  directed  on  page  151.     If  any 


PRACTICAL  FEEDING.  157 

one  of  these  gruels  agrees,  the  strength  may  be  increased  to  two  ounces 
of  flour  to  the  quart.  Such  gruels  will  contain  about  0.80  per  cent, 
protein  and  5  per  cent,  carbohydrates,  except  the  legume  gruel,  which 
will  contain  about  1.5  per  cent,  proteins  with  about  5  per  cent, 
carbohydrates. 

2.  Whey,  made  as  directed  on  page  154,  may  be  tried,  which  will 
contain  about  the  same  quantities  of  protein  and  carbohydrates 
as  the  gruels  made  with  two  ounces  of  flour  to  the  quart. 

3.  The  white  of  one  egg  beaten  up  in  eight  ounces  op 
WATER  may  be  retained  when  nothing  else  is  tolerated.  Such  a  mix- 
ture contains  about  1.5  per  cent,  of  protein,  but  no  carbohydrates  or 
fat.     Its  nutritive  value  is  not  great. 

4.  White  of  egg  and  dextrinized  gruel,  made  by  beating  up 
the  white  of  one  egg  with  eight  ounces  of  dextrinized  wheat  flour  gruel 
(1  ounce  to  quart)  will  sometimes  agree.  If  it  is  acceptable,  one  to 
two  even  teaspoonfuls  of  granulated  sugar  may  be  added  to  the  eight- 
ounce  mixture,  which  will  then  have  about  the  following  composition, 
protein  2  per  cent,  and  carbohydrates  6  per  cent. 

5.  Yolk  of  egg  and  dextrinized  gruel,  made  by  adding  the  yolk 
of  one  fresh  egg  to  eight  ounces  of  dextrinized  wheat  flour  gruel  (1 
ounce  to  quart),  and  if  tolerated  adding  one  to  two  level  teaspoonfuls 
of  granulated  sugar,  is  highly  nutritious  and  especially  rich  in  blood 
making  substances.  If  well  borne  in  malnutrition  cases  legume  flour 
may  be  used  in  place  of  the  wheat  flour.  This  will  increase  the  quan- 
tity of  nucleoproteids  in  the  food  materially. 

6.  Meat  broths  oftentimes  arouse  the  appetite,  and  if  acceptable 
may  be  mixed  with  dextrinized  gruels  made  with  two  to  three  ounces 
of  flour  to  the  quart,  in  equal  parts,  or  they  may  be  thickened  with 
the  gruel  flours  by  stirring  in  an  ounce  of  flour  to  the  quart  of  broth 
and  boiling.     This  will  make  a  thick  broth. 

To  make  broths,  take  one  pound  of  lean  mutton,  veal,  or  chicken 
with  some  cracked  bone  and  cut  into  small  squares;  add  one  pint  of 
cold  water,  heat  gently,  and  allow  to  simmer  for  about  three  hours. 
Strain  and  add  enough  boiled  water  to  make  a  pint  of  broth.  When 
cool  remove  the  fat  or  skim  it  ofif  while  hot.  The  broth  will  be  gelat- 
inous when  cold  and  should  be  served  warm. 

7.  Beef  tea  is  often  useful  as  a  digestive  stimulant  and  is  made 
by  taking  a  pound  of  lean  beef  and  cutting  it  into  small  pieces  and 
allowing  it  to  stand  in  a  pint  of  cold  water  for  an  hour.  It  is  then 
heated  to  not  above  160°  F.,  and  the  meat  is  expressed  through  cheese 
cloth.  If  heated  to  above  this  temperature  the  albumin  of  the  meat 
will  coagulate.     If  the  coagulum  is  allowed  to  remain  in  the  tea  none  of 


158  DISEASES  OF  CHILDREN. 

the  nutritive  value  will  be  lost,  but  if  it  is  removed  the  tea  will  have 
little  but  flavor. 

8.  Beef  Juice  is  often  a  useful  addition  to  other  foods  in  cases 
of  malnutritix)n  and  may  be  made  as  follows : 

a.  Slightly  broil  a  thick  piece  of  round  steak  that  is  perfectly 
free  from  taint.     Cut  into  small  pieces  and  press  in  a  clean 
meat  press  or  lemon  squeezer. 
6.  Cut  the  fresh  steak  into  small  pieces  and  just  cover  with  cold, 
slightly  salted  water,  and  set  on  ice  for  several  hours.     Then 
press  by  squeezing  in  a  piece  of  cheese-cloth. 
The  quantity  of  beef  juice  given  should  not  be  over  one  ounce 
in  twenty-four  hours,  and  it  is  given  to  best  advantage  when  added  a 
teaspoonful  at  a  time  to  other  feedings,  as  in  larger  quantities  the  in- 
fant soon  tires  of  it. 

If  any  of  the  mixtures  just  given  agrees,  attempts  at  adding  fresh 
cow's  milk,  a  teaspoonful  at  a  time,  may  be  made.  If  the  milk  is 
tolerated  the  quantity  may  be  increased  cautiously  until  it  forms  one- 
fourth  of  the  mixture,  when  the  fats  may  be  increased  and  the  infant 
can  be  put  on  a  formula  suitable  for  its  age  as  indicated  on  page  149. 

When  All  Attempts  at  Adding  Fresh  Milk  Fail. 

When  infants  fail  to  thrive  on  any  of  the  foregoing  mixtures  and 
all  attempts  at  giving  fresh  milk  in  any  quantity  fail,  the  following 
mixtures  may  be  tried  and  often  are  highly  successful.  Whenever 
the  foods  that  are  cooked  are  used,  a  teaspoonful  or  two  of  beef  juice 
or  orange  juice  should  be  given  daily,  as  on  such  foods  infants  are 
liable  to  develop  scurvy. 

Formula  No.  1. 

Whole  milk 12  ounces. 

Wheat  or  oat  gruel  flour 4  level  tablespoonfuls. 

Granulated  sugar 2  level  tablespoonfuls. 

Salt 1  pinch. 

Cold  water 22  ounces. 

Mix  cold  and  with  constant  stirring  slowly  bring  to  a  boil  and  boil  for  three 
minutes.  Strain  and  add  enough  boiled  water  to  make  thirty-two  ounces.  Feed 
quantity  appropriate  for  age.  For  young  infants  or  very  delicate  ones  the  food 
may  be  diluted  with  one  part  of  water  to  two  parts  of  the  food. 

Approximate  Composition.— Fai,  1.5  per  cent.;  carbohydrates  (starch,  milk- 
sugar,  cane-sugar),  7  per  cent.;  protein,  1.5  per  cent. 

By  using  the  top  16  ounces  from  one  quart  of  milk  and  taking  12  ounces  of 
this  instead  of  whole  milk  in  the  above  mixture  the  percentages  will  be:  Fat, 
2.5  per  cent.;  carbohydrates,  7  per  cent.;  and  protein,  1.5  per  cent. 


PRACTICAL  FEEDING.  159 

Formula  No.  2. 

Whole  milk 12  ounces. 

Wheat  or  oat  gruel  flour 4  level  tablespoonfuls. 

Glycerite  of  diastase  (Cereo) 3  teaspoonfuls. 

Salt 1  pinch. 

Cold  water 22  ounces. 

Mix  cold  and  with  constant  stirring  bring  slowly  to  a  boil,  and  boil  for  five 
minutes.  Strain  and  add  enough  boiled  water  to  make  32  ounces.  Feed  quantity 
appropriate  for  age,  or  dilute  two  parts  of  the  food  with  one  part  of  water  for 
very  young  or  delicate  infants. 

Approximate  Composition. — Fat,  1.5  per  cent.;  carbohydrates  (soluble  starch, 
dextrin,  maltose,  milk-sugar),  6  per  cent.;  proteins,  1.8  per  cent. 

If  top  16  ounce  milk  is  used  instead  of  whole  milk,  the  percentage  of  fat  will 
be  2.5  per  cent. 

With  both  of  the  formulas  above  it  will  be  better  to  begin  with 
whole  milk  and  increase  to  top  sixteen  ounce  milk  if  digestion  is  good. 

Keller's  malt  soup  is  a  mixture  similar  to  the  above.  It  is  made 
by  boiling  milk,  water,  wheat  flour,  and*  Loeflund's  malt  soup  extract 
together.  The  carbohydrates  in  the  mixture  are  starch,  maltose,  and 
milk-sugar. 

A  few  cases  may  be  met  in  which  no  food  previously  suggested 
agrees.  In  these  cases  condensed  milk,  peptonized  milk,  or  buttermilk 
may  solve  the  problem. 

Condensed  Milk  Mixtures. — Fresh  condensed  milk  is  to  be  preferred, 
but  if  unobtainable  the  best  brands  of  sweetened  condensed  milk 
should  be  employed.  A  teaspoonful  of  condensed  milk  to  four  ounces 
of  plain  or  dextrinized  gruel  may  be  used  at  the  start.  If  this  is  well 
borne,  the  quantity  of  condensed  milk  should  be  rapidly  increased  until 
two  to  four  teaspoonfuls  to  four  ounces  of  diluent  are  used.  Then 
equal  parts  of  cream  from  bottled  milk  and  condensed  milk  should 
be  mixed  and  used  for  dilution,  which  may  be  reduced  until  one  part 
of  this  mixture  is  used  with  five  parts  of  diluent,  which  will  give  a 
mixture  of  about  the  following  composition:  Protein,  1  to  1.5  per 
cent.;  fat,  2  to  3  per  cent.;  carbohydrates,  6  to  8  per  cent. 

Peptonized  Milk.  Warm  Process. — (1)  Empty  into  a  clean  quart 
bottle  the  contents  of  one  of  Fairchild's  peptonizing  tubes;  (2)  add 
four  ounces  (eight  tablespoonfuls)  of  cold  water;  shake,  and  (3)  add 
one  pint  of  cool  fresh  milk  and  again  shake;  (4)  place  the  bottle  in 
water  not  too  hot  to  be  uncomfortable  to  the  hand  for  ten  minutes. 
Then  either  place  on  ice  or  boil  to  prevent  further  digestive  action. 
This  milk  is  likely  to  taste  bitter. 

Cold  Process. — Prepare  the  bottle  as  before,  but  set  on  ice  without 
warming.  This  milk  is  only  partially  peptonized  so  will  not  have  a 
bitter  taste. 


160 


DISEASES  OF  CHILDREN. 


Buttermilk. — For  temporary  use  buttermilk  has  a  limited  field. 
It  is  best  made  at  home  by  using  one  of  the  lactic  acid  ferments  on  the 
market.  These  consist  of  lactic  acid  bacteria  which,  when  placed  in 
milk,  produce  lactic  acid  from  a  portion  of  the  milk-sugar,  which 
precipitates  the  casein.  Natural  buttermilk  contains  little  fat,  as 
this  has  been  removed  as  butter.  In  making  buttermilk  the  cream 
may  be  removed  and  the  ferment  added  to  the  skimmed  milk,  or 
whole  milk  may  be  used. 

Two  types  of  buttermilk  food  are  employed.  First,  the  raw 
buttermilk,  which  contains  enormous  numbers  of  lactic  bacteria; 
second,  buttermilk  to  which  one  ounce  of  flour  (four  level  tablespoon- 
fuls)  is  added  to  the  quart,  and  boiled.  Raw  buttermilk  introduces 
harmless  bacteria  into  the  digestive  tract  which  may  kill  off  those 
present  that  are  harmful.  Cooked  buttermilk  supplies  a  fairly  sterile 
acidified  food  in  which  the  casein  is  finely  divided  and  cannot  form  a 
solid  mass  in  the  stomach. 

Laboratory  Feeding. — In  many  of  the  larger  cities  are  to  be  found 
the  Walker-Gordon  laboratories  at  which  food  for  infants  is  prepared 
upon  prescription  of  the  physician.  They  were  established  as  the 
results  of  Rotch's  teachings.  In  their  early  days  the  food  was  pre- 
pared upon  the  principle  that  all  differences  in  milks  of  different  species 
were  due  merely  to  differences  in  percentage  composition  and  in  their 
reaction  to  litmus-paper,  and  the  prescription  blank  employed  was 
gotten  up  on  this  basis. 

The  Walker-Gordon  Laboratory. 


Per  cent. 


Remarks. 


^ 


Fat 

Milk-sugar 

Albuminoids  .  . 
Mineral  matter 
Total  solids  .  .  . 
Water 


100  00 


For  whom  ordered. 


Date, 


Number  of 

feedings? 

Amount  at 
each  feedings?  .  . 
Infant's  age?  .  .  . 
Infant's  weight? 


Signature, 


If  the  physician  does  not  care  to  mention  the  especial  percentages,  he  can  ask 
for  percentages  which  will  correspond  to  the  analysis  of  average  human  milk,  and 
he  can  then  vary  any  or  all  of  these  percentages  later,  according  to  the  need  of  the 
special  infant  prescribed  for. 


PRACTICAL  FEEDING. 


161 


But  with  the  increase  in  knowledge  of  the  properties  and  functions 
of  milks  of  different  species,  and  of  the  effect  of  the  various  additions 
to  and  manipulations  of  milk,  which  made  it  acceptable  to  infants,  a 
new  and  broader  prescription  blank  was  prepared  which  is  now 
available. 


Fats 

I  Lactose  (Milk  Sufar) 
Maltose  (Malt  Sugar) 
Sucrose  (Cane  Sugar) 
Dextrose   (Grape    Sugar) 
Starch 

(b)  Dexlrinize 

(c)  Proteids |  whey 

i  Casein 

(d)  Peptonize 

(e)  Sodium  Citrate    .  .      i  %  of  milk  and  cream 

I  %  of  total  mixture 

(f)  Sodium  Bicarb.  ...  |  %  of  milk  and  cream 

(  %  of  total  mixture 

(g)  Lime  Water I  %  °f  ■"'"'  '"^  """" 

I  %  of  total  mixture 

I  artir  Arid  f  ^  ^°  '"''''''•  '''"  ^"■"■°" 

Ch)  h     .  .  ]       Pl>y'e8  of  fermentation 

*-    ''  Bacillus         "^  2  To  facilitate  digestion 

I      of  the  proteids 


Per  Cent, 


Heat    at_ 


^°F. 


EXPLANATORY 

(a)  It  requires  .75%  starch  to  make 
the  precipitated  casein  finer. 

(b)  One  hour  completely  dextrinizes 
the  Starch. 

(c)  In  case  physicians  do  not  wish 
to  sub-divide  the  proteids,  the  words 
"Whey"  and  "Casein"  may    be    erased. 

(d)  Twenty  minutes  renders  the  mix- 
ture decidedly  bitter. 

(e)  It  requires  0.20%  of  the  milk 
and  cream  used  in  modifying  to  facilitate 
the  digestion  of  the  proteids;  i.  e.,  the 
formation  of  a  soft  curd.  0.40%  to  pre- 
vent the  action  of  rennet ;  i.  e.,  the  for- 
mation of  tough  curd. 

(f)  It  requires  68%  of  the  milk  and 
cream  used  in  modifying  to  favor  the 
digestion  of  the  proteids.  1.70%  of  the 
amount  of  milk  and  cream  used  suspends 
all  action  on  the  proteids  in  the  stomach. 
.17%  of  the  total  mixture  gives  a  mild 
alkaline  food. 

(g)  It  requires  20%  of  the  milk  and 
cream  used  in  modifying  to  favor  the  di- 
gestion of  the  proteids.  50%  of  the 
amount  of  milk  and  cream  used  suspends 
all  action  on  the  proteids  in  the  stomach. 
5%  of  the  total  mixture  gives  a  mild 
alkaline  food. 

(h)  Percentage  figures  represent  the 
per  cent,  of  Lactic  Acid  attained  when 
the  food  is  removed  from  the  thermostat. 
When  the  Lactic  Acid  Bacillus  is  used  to 
facilitate  digestion  of  the  proteids,  this  is 
the  final  acidity,  as  the  process  is  stopped 
by  heat  at  this  point.  When  the  Lactic 
Acid  Bacillus  is  used  to  inhibit  the 
growth  of  saphrophytes,  the  acidity  may 
subsequently  increase  to  a  variable  de- 
gree, as  the  bacilli  are  left  alive.  .25% 
Lactic  Acid  just  curdles  milk.  .50% 
gives  thick  curdled  milk.  .75%  sepa- 
rates into  curds  and  whey. 

WALKER-GORDON   LABORATORY  CO. 

793  Boylston  Street,   Boston 

And  all  Large  Cities 

The  products  of  the  laboratories,  however,  are  not  available  for 
the  majority  of  physicians. 
11 


Number    of    Feedings 


Amount  at  each  Feeding. 


ORDERED  FOR 


Adrlrfss 

D^t.. 

190 

M.  D 

NOTE— See  ba«k  of  pad. 

162  DISEASES  OF  CHILDREN. 

Calorie  Feeding. — An  attempt  has  been  made  to  establish  a  calori- 
metric  standard  for  use  in  feeding  infants,  which  at  first  thought  seems 
simple  and  interesting,  but  it  is  based  on  incorrect  principles.  A 
•Calorie  is  a  measure  of  heat,  being  the  amount  of  heat  required  to  raise 
the  temperature  of  one  liter  of  water  one  degree  Centigrade.  Heat, 
as  is  well  known,  is  produced  by  chemical  action,  friction,  mechanical 
movements,  and  in  the  utilization  of  food  by  the  animal  organism. 

It  has  been  determined  by  experiment  just  how  much  heat  is 
produced  by  the  oxidation  of  practically  all  food  substances  and 
the  burning  of  different  kinds  of  fuel.  In  mechanical  operations  it  is 
possible  to  calculate  closely  from  the  amount  of  heat  obtainable  from 
any  substance  the  amount  of  work  it  can  be  made  to  perform.  And, 
conversely,  to  calculate  the  amount  of  fuel  needed  to  perform  any 
required  amount  of  work.  As  infants  and  animals  are  constantly  pro- 
ducing heat  and  excreting  it,  by  measuring  the  quantity  of  the  heat 
it  becomes  possible  to  determine  how  much  food  is  required  to  be 
burned  to  produce  this  amount  of  heat. 

When  animals  are  used  to  supply  mechanical  power  this  process 
of  determining  the  amount  of  food  or  fuel  necessary  is  useful,  within 
certain  limits,  but  the  ease  with  which  the  food  is  assimilated  is  an 
important  factor,  for  with  some  classes  of  foods  not  one-half  of  the 
amount  of  heat  the  food  is  capable  of  producing  becomes  available, 
the  greater  portion  being  wasted  in  the  process  of  assimilation.  In 
selecting  food  for  infants  the  primary  object  is  not  to  convert  the 
energy  content  of  food  into  heat,  but  to  supply  materials  from  which 
blood,  muscle,  and  bone  can  be  constructed. 

An  ounce  of  food  containing 

,  1  per  cent,  fat  yields 1.8    Calories 

1  per  cent,  proteins  yields 1.23  Calories 

1  per  cent,  carbohydrates  yields 1.23  Calories 

and  if  the  amount  of  heat  the  food  would  supply  was  all  that  determined  its 
suitability  for  infant-feeding  it  would  make  no  difference  if  the  food  was  all  fat  or 
proteins  or  carbohydrates. 

A  mixture  which  is  much  used  in  feeding  infants  contains  protein  1  per  cent, 
fat  3  per  cent.,  and  carbohydrates  6  per  cent.  By  multiplying  the  percentages, 
of  each  ingredient  by  the  number  of  Calories  each  per  cent,  will  yield,  it  will  be 
found  that  one  ounce  of  this  mixture  yields  seventeen  Calories.  The  following 
formulas  show  a  few  mixtures  of  widely  differing  composition,  each  of  which 
yields  seventeen  Calories  to  the  ounce: 


Protein 0.5%;i.0% 

Fat   3.0%  3.0% 

Carbohydrates    .  . .  6 . 5%  ;6 . 0% 


1.5% 
3.0% 

5.5% 


2.0% 

3.0% 
5.0% 


2.5%  3.0%  3.5%  2.0% 
3.0%  3.0%  1.0%  1.5% 
4.5%!4.0%8.0%8.0% 


3.0% 
1.5% 
7.0% 


3.0% 
2.0% 
6.0% 


In  practice  these  formulas  would  not  be  interchangeable,  although  from  the 

calorimetric  standpoint  they  are  equally  valuable. 


PRACTICAL  FEEDING.  163 

As  infant-feeding  centers  around  a  supply  of  protein,  and  the  well- 
being  and  development  of  the  infant  depend  absolutely  upon  a  suffi- 
cient supply  of  this  element  of  food,  the  standard  is  being  modified 
to  include  the  principle  that  a  certain  pr.oportion  of  the  food  be  com- 
posed of  proteins. 

The  amount  of  heat  an  infant  will  excrete  will  depend  upon  the 
character  of  its  food,  and  the  season  of  the  year.  Food  that  is 
difficult  of  digestion  causes  more  heat  to  be  excreted  than  easily 
-digested  food,  and  sometimes  gain  in  weight  can  be  made  on  a 
smaller  quantity  of  easily  digested  food  when  no  gain  is  made  on  a 
much  larger  quantity  of  food  that  requires  more  digestive  effort. 
In  hot  weather  the  infant  does  not  need  food  to  supply  heat,  as  it  has 
no  need  for  it,  and  is  constantly  excreting  surplus  heat  produced  by 
its  mechanical  movements.  Under  certain  conditions  the  whole  suc- 
cess of  managing  infants  during  the  heated  term  depends  upon  re- 
ducing the  amount  of  heat  it  produces,  and  food  that  produces 
little  heat  is  given,  or  none  at  all,  and  the  infant  is  sponged  to  aid  in  re- 
moving the  heat  unavoidably  produced. 

In  practice  the  calorimetric  standard  will  be  found  to  possess  no 
advantages  over  the  standards  generally  used  except  possibly  as  a 
check  on  the  total  quantity  of  food. 

Directions  for  the  Mother  or  Nurse. 

Education  of  Mother  Necessary. — One  of  the  greatest  aids  in  the 
feeding  of  infants  artificially  is  intelligent  cooperation  of  the  mother, 
and  it  should  be  explained  to  her  that  as  she  would  naturally  feed  the 
infant  until  its  digestive  organs  are  sufficiently  developed  to  digest 
soft  table  food,  (Fig.  25  page  90),  it  is  her  duty  to  become  acquainted 
with  the  details  of  preparing  and  administering  artificial  food.  Time 
expended  in  teaching  a  mother  how  to  prepare  food  and  why  the  dififer.- 
ent  processes  are  used  will  be  well  spent  and  will  eventually  repay  the 
physician. 

The  mother  or  nurse  should  be  shown  just  what  she  is  expected  to 
do.  Directions  should  be  written  out.  The  feeding  schedule  on  page 
149  may  be  followed  as  a  general  guide  as  to  what  the  formulas  for 
different  ages  should  be  and  the  pictorial  directions  (page  148)  when 

-shown  to  a  mother  will  make  things  clearer  than  long  explanations. 

i         Care  of   Food. — When   a  good,  clean  milk  cannot  be  obtained, 
or  when  the  conditions  are  such  that  the  food  after  being  prepared 

■  cannot  be  kept  below  50°  F.,  it  should  be  pasteurized.     The  fact  that 
the  food  is  kept  in  a  refrigerator  does  not  necessarily,  mean  that  it  is 


164 


DISEASES  OF  CHILDREN. 


kept  cool,  as  the  temperature  in  some  refrigerators  is  above  60°  F. 
The  food  should  be  kept  surrounded  by  ice. 

Nursing  bottles  of  the  style  shown  in  Fig.  47  should  be  used,  as 
they  can  be  readily  cleaned.  After  the  food  is  placed  in  them  they 
should  be  stoppered  with  clean  absorbent  cotton.  Corks  should 
not  be  used,  as  the  milk  gets  into  the  pores  and  sours,  or  otherwise 
spoils  and  infects  the  next  feeding. 

If  the  food  is  to  be  pasteurized  the  Freeman  pasteurizer  (Fig.  48) 
or  Arnold  Sterihzer  (Fig  49)  may  be  used,  or  when  these  are  not  avail- 


FiG.  47.  — 
Nursing  bottle, 
preferable. 


Fig.  48. — Freeman  pasteurizer. 


able  a  home-made  pasteurizer  may  be  employed  (Figs.  50,  51).  This 
is  made  from  a  six  quart  tin  pail.  A  false  bottom  is  made  by  punch- 
ing holes  in  a  tin  pie  plate  which  is  then  inverted  in  the  pail.  The  bot- 
tles of  food  or  milk  are  placed  on  the  false  bottom,  and  water  is  poured 
around  them  up  to  the  level  of  the  milk.  The  pail  is  then  placed  on  a 
stove  and  the  water  brought  to  a  temperature  of  165°  F.,  as  determined 
by  a  thermometer.  The  pail  is  now  covered  with  a  cloth  and  removed 
from  the  stove,  and  allowed  to  stand  for  half  an  hour.  A  folded  news- 
paper is  a  good  thing  to  stand  the  pail  on  as  it  will  prevent  too  rapid 
loss  of  heat.  After  standing  half  an  hour  the  food  or  milk  should  be 
cooled  by  placing  it  in  cold  water,  until  thoroughly  cooled,  otherwise 
the  bacterial  spores  which  are  not  destroyed  by  pasteurizing  will 
germinate  and  may  cause  disturbance  of  the  infant's  digestive  tract. 
Old  pasteurized  milk  should  never  be  used.  Fresh  food  should  be 
made  every  day. 


PRACTICAL  FEEDING. 


165 


Administration  of  Food. — Regularity  in  feeding  should  be  in- 
sisted upon.  The  food  should  be  shghtly  warmed  by  placing  the  bottle 
in  warm  water  for  a  few  minutes.      Night  feedings  should  not  be 


Fig.  49. — Arnold  sterilizer. 

warmed  before  retiring  and  kept  warm.  This  is  a  pernicious 
practice.  The  cotton  stopper  is  then  removed  and  a  black  rubber 
nipple  should  be  placed  on  the  bottle  which  should  be  inverted  to 
see  that  the   hole  in  the  nipple  is  large  enough  to  allow  the  food  to 


yQv 


A 


-V^" 

^ 


^^fc^ 


Fig.  50 — Home-made 
pasteurizer.  (Russell.) 


Fig.  51. — Pasteurizer  for  bottled  milk. 
(Russell.) 


drop  slowly,  but  not  so  large  as  to  permit  the  food  to  run  in  a  stream. 
The  mother  or  nurse  should  be  cautioned  not  to  put  the  nipple  in  her 
mouth.  By  allowing  the  food  to  drop  on  the  wrist  it  will  be  possible 
to  determine  whether  it  is  too  hot  or  too  cold. 


166 


DISEASES  OF  CHILDREN. 


The  infant  should  not  be  over  twenty  minutes  in  taking  its 
food,  and  if  satisfied  will  drop  off  to  sleep.  Never  use  the  food  that 
may  be  left  in  the  bottle,  but  throw  it  away.  If  a  considerable 
portion  of  the  food  is  left  in  the  bottle  the  nipple  should 
be  examined  to  see  if  the  hole  is  too  small  or  has  become 
clogged. 

Care  of  Utensils. — After  preparing  food  the  dipper, 
double  boiler,  bottles,  spoons,  and  all  articles  that  have 
been  used  should  be  washed,  first  with  cold  water,  and 
then  with  soap  or  washing  compound  and  hot  water,  and 
then  scalded.  The  bottles  should  be  cleaned  with  a 
brush  (Fig.  52),  and  after  being  scalded  should  be  kept 
inverted  until  ready  to  be  filled  again.  The  nipples 
should  be  thoroughly  washed  and  kept  lying  in  a  cup  of 
water  in  which  a  good-sized  pinch  of  borax  has  been 
dissolved. 

Examination    of    Stools. — The    mother    should    be 
taught  to  examine  the  stools  and  to  report  to  the  physi- 
cian the  appearance  of  anything  abnormal,  as  change  of 
color,   diarrhea,  the  appearance  of  curds   or   of  mucus. 
The  mother  should  not  be  taught  that  these  are  alarming  symptoms, 
but  that  they  indicate  something  is  wrong  and  needs  attention. 


Fig.  52.— 
Bottle  brush 


How  to  Interpret  Results. 

Weighing  the  Infant  Important. — Infants  should  be  weighed  at 
regular  intervals  in  about  the  same  clothing,  as  steady  gain  in  weight 
is  one  of  the  indications  that  they  are  thriving  on  their  food.  But 
judging  the  value  of  a  food  by  the  mere  fact  that  it  causes  gain  in 
weight  is  quite  wrong  as  the  gain  may  be  only  in  fat. 

The  composition  of  the  food,  (see  page  145),  the  general  develop- 
ment and  gain  in  weight  should  be  taken  into  consideration,  and  no 
infant  should  be  dismissed  until  its  food  contains  considerably  over 
one  per  cent,  of  protein  and  it  is  gaining  in  weight  on  it. 

The  gain  in  weight  is  greatest  in  proportion  during  the  first  few 
months,  as  food  is  assimilated  more  completely  at  this  period,  as  has 
been  explained  on  page  135.  Just  how  much  an  infant  should  gain 
each  week  cannot  be  stated  definitely,  as  infants  vary  in  this  respect. 
Some  will  gain  a  pound  and  others  not  over  two  ounces,  butiihe  latter 
gain  is  too  small  for  a  healthy  infant.  Six  ounces  is  a  good  gain.  If 
the  food  is  agreeing  the  quantity  or  strength  may  be  increased  cau- 
tiously to  see  if  greater  gain  will  result,  but  this  plan  must  not  be  pushed' 


PRACTICAL  FEEDING. 


167 


to  an  extreme,  for  loss  instead  of  gain  may  result.  A  record  of  the 
weight  should  be  kept  on  a  weight  chart,  according  to  the  plan  shown 
in  Fig.  54.  Weight  charts  have  been  prepared  on  which  is  shown 
the  "normal  weight  curve"  deduced  from  the  average  gains  of  a 
large  number  of  infants.  It  is  better  not  to  use  this  style  of  weight 
chart,  as  few  infants  pass  their  first  year  without  some  ups  and  downs, 
and  the  slightest  variation  from  the  "normal  curve"  is  a  cause  of 
worry  and  anxiety  to  the  mother  and  through  her  to  the  physician. 


Fig.  53. — Weighing  the  infant 


Feeding  in  Hot  Weather. — Upon  the  advent  of  hot  weather  special 
precautions  should  be  taken  to  forestall  attacks  of  gastroenteritis. 
The  means  for  keeping  the  food  cool  should  be  looked  after,  and  tested 
with  a  self-registering  thermometer,  or  the  food  should  be  kept  packed 
in  ice  to  make  sure  it  is  kept  cool.  Pasteurization  may  be  necessary 
if  ice  is  not  available.  If  the  infant  has  a  tendency  to  indigestion  or 
to  vomiting,  the  amount  of  fat  in  the  food  should  be  reduced  by  using 
whole  milk  instead  of  top  milk  in  making  the  food.  One  or  two  feed- 
ings of  gruel  used  as  the  diluent  may  be  put  up,  and  given  as  night 
feedings  or  as  substitutes  when  milk  feedings  seem  to  disagree. 

If  the  air  is  humid  and  the  temperature  high,  the  infant  should 
be  given  a  sponge  bath  twice  a  day.  The  excess  of  body  heat  is  ex- 
creted by  the  evaporation  of  perspiration,  and  this  is  retarded  by  high 


168 


DISEASES  OF  CHILDREN. 


humidity.     And  unless  the  skin  is  kept  clean  and  free  from  the  residue 

from  the  evaporation  of  perspiration,  this  will  also  retard  evaporation. 

Feeding  when  Traveling. — Changes  in  the  food  are  risky  at  any 

time  and  especially  so  when  traveling.     A  good  plan  to  follow  is  to  have 


WEIGHT  IN  GRAMS. 

i   i   i  I   I 


»:i««';«s;-t  «i--t  5;:^st-t«-t^-ti^'i:x--';»r  -t  :,•?  at  s^xs:  site's  i^if!:;.t  atsi'sc^wte  :s;K'»te,s? 

•SaNnOd  Nl  ±H0I3M 


the  regular  food  prepared  and  packed  in  ice  to  insure  thorough  cooling 
and  then  to  place  it  in  vacuum  bottles,  such  as  the  Thermos  (Fig.  55). 
The  bottles  should  be  filled  right  up  to  the  stopper,  otherwise  the  agi- 
tation of  the  food  will  churn  the  milk  so  that  the  fat  will  separate  as 


PRACTICAL  FEEDING. 


169 


butter.  Several  of  these  bottles  will  be  required  if  the  journey  is  to 
last  several  days.  If  there  is  a  question  about  the  food  being  kept  cool, 
it  should  be  pasteurized,  then  cooled  or  iced  if  possible,  before  being 
put  into  the  vacuum  bottle.  These  bottles  while  expensive  will  be 
found  useful  to  those  who  can  afford  them.  They  will  keep  food  cold 
for  about  seventy-two  hours  or  hot  for  about  twenty-four  hours. 

The  food  for  the  infant  can  be  poured  from  the  vacuum  bottle 
into  a  clean  nursing  bottle  and  warmed  as  wanted.  But  the  food 
should  be  slightly  shaken  so  as  to  mix  the  cream 
which  will  have  risen  to  the  top  with  the  remaining 
milk.  The  food  should  not  be  warmed  and  then 
kept  in  one  of  these  bottles  to  save  warming.  Milk 
soon  spoils  if  kept  warm. 

For  a  single  day's  journey  the  food  may  be  put 
up  as  usual  in  the  home  and  boiled  and  then  iced 
and,  when  cold,  wrapped  in  newspaper,  each  bottle 
being  wrapped  separately;  or  the  food  may  be  put 
in  a  pail  with  cracked  ice  around  the  bottles,  which 
is  preferable. 

When  it  is  not  possible  to  have  the  foregoing 
directions  carried  out,  one  of  the  best  brands  of 
sweetened  condensed  milk  diluted  with  boiled  water 
may  be  used.  The  boiled  water  may  be  carried  if 
it  will  not  be  obtainable  during  the  journey. 

Feeding  when  Away  from  Home. — During  the 
heated  term  large  numbers  of  families  leave  the 
cities  and  live  in  the  country  at  boarding  houses, 
hotels,  or  in  their  own  homes.  In  many  of  the  more 
remote  districts  the  milk-supply  problem  has  not  yet  been  solved  and 
much  disturbance  may  be  caused  by  milk  which  has  been  improperly 
handled  through  ignorance. 

In  such  instances  the  mother  should  make  an  arrangement  with 
some  milkman  or  farmer  to  supply  milk  produced  under  sanitary  con- 
ditions. The  farmer  should  be  instructed  to  clean  the  cows  as  thor- 
oughly as  he  cleans  his  horses,  to  wipe  the  belly  and  udder  with  a 
damp  cloth  before  milking,  to  wash  his  hands  before  milking,  and  to 
reject  the  first  two  or  three  jets  from  each  teat.  The  milk  pail  should 
be  well  washed  and  scalded  after  being  used  and  kept  inverted  in  the 
sun.  As  soon  as  the  milking  is  finished  the  milk  should  be  mixed,  as 
it  is  not  uniform  in  composition  as  it  leaves  the  cow,  and  then  poured 
into  quart  milk  bottles.  These  should  be  set  in  ice-water,  or  if  this 
is  not  obtainable,  into  cold  well  water  which  rises  nearly  to  the  tops 


Fig.  55. — Thermos 
vacuum  bottle. 


170  DISEASES  OF  CHILDREN. 

of  the  bottles.  The  milk  can  be  delivered  in  the  morning  in  time  to 
prepare  the  food  for  the  day. 

Such  milk  will  cost  more  than  the  ordinary  milk,  but  it  is  worth 
all  it  costs,  and  will  be  found  cheaper  in  the  end.  The  mother  should 
see  for  herself  that  the  milk  is  produced  under  cleanly  conditions. 
She  would  not  tolerate  a  filthy  wet-nurse  for  her  infant  and  should  not 
allow  her  infant's  food  to  come  from  a  filthy  cow. 

Feeding  Among  the  Poor. — The  preparation  of  food  or  even 
obtaining  suitable  food  materials  is  often  a  perplexing  problem  among 
the  poor  and  in  the  tenements  of  large  aities.  The  intelligence  of  the 
mother  may  be  limited  and  even  when  the  mother  is  capable  of  carry- 
ing out  directions  the  facilities  for  preparing  food  and  keeping  it 
cool  are  wanting.  Some  families  are  too  poor  to  buy  clean  bottled 
milk  at  ten  cents  a  quart  and  oftentimes  such  milk  is  not  offered 
for  sale  in  the  poorer  sections  of  a  community. 

Correct  dietetic  principles  must  be  applied  as  best  they  can  be. 
Where  good  milk  can  be  obtained,  but  careful  modification  cannot 
be  expected,  the  food  may  be  made  with  whole  milk  and  gruel,  using 
one-fourth,  one-third,  and  one-half  milk  and  adding  one  part  of 
granulated  sugar  to  thirty-three  parts  of  food,  or  two  level  table- 
spoonfuls  to  the  quart  of  food. 

Where  good  milk  is  unobtainable,  condensed  milk  may  be  used 
with  water  or  barley  gruel  made  with  one  ounce  of  flour  to  the  quart. 
The  milk  should  be  diluted  8  to  15  times,  that  is,  one  part  of  condensed 
milk  to  7  to  14  parts  of  water  or  gruel.  No  sugar  is  to  be  added. 
Cod-liver  oil  or  olive  oil  can  be  given  daily,  one  teaspoonful  three  times 
a  day  to  supply  the  fats. 

Infant's  Food  Dispensaries. — The  unsatisfactory  results  obtained 
in  infant-feeding  among  the  tenement  population,  owing  to  improper 
preparation  of  food  or  lack  of  suitable  food,  has  led  to  the  establish- 
ment of  food  dispensaries  in  the  crowded  sections  of  many  cities. 
There  are  three  types  of  these  feeding  stations:  (1)  Those  at  which  a 
few  formulas  of  modified  milk  may  be  obtained  in  nursing  bottles  by 
anyone  who  applies  for  them,  no  supervision  of  the  cases  being  made. 
(2)  Those  at  which  fixed  modifications  of  milk  are  given  out  by  trained 
nurses  or  physicians  who  examine  the  applicants  and  aim  to  give  a 
formula  which  is  likely  to  agree.  (3)  Those  at  which  the  food  is 
prepared  for  each  infant  while  it  waits,  upon  the  prescription  of  the 
attending  physician. 

The  feeding  stations  at  which  food  is  dealt  out  without  taking  into 
consideration  the  condition  of  the  infant  are  not  to  be  encouraged,  for 
while  they  do  much  good,  they  also  do  harm. 


PRACTICAL  FEEDING.  171 

Where  the  infant-feeding  problem  among  the  poor  is  handled  on  a 
large  scale  and  physicians  who  have  not  had  wide  experience  in  feeding 
infants  and  in  the  actual  processes  of  preparing  food  see  the  patients, 
the  second  type  of  feeding  station  will  be  most  successful.  For  these 
stations  the  food  is  prepared  at  a  central  station  on  a  large  scale  and 
delivered  iced  to  the  local  stations,  where  the  mothers  bring  their  babies, 
and  the  physician  or  nurse  in  attendance  examines  them  and  orders  a 
food  mixture.  The  formulas  given  on  page  149  may  be  followed  closely, 
and  if  the  infants  are  not  acutely  ill,  digestively,  beginning  with  a  weak 
mixture  and  going  from  this  to  stronger  ones  will  be  found  quite  satis- 
factor^^  During  the  heated  term  feedings  of  plain  and  dextrinized  gruels 
made  with  one  to  two  ounces  of  barley  or  oat  gruel  flour  to  the  quart 
should  be  kept  on  hand  to  be  given  when  milk  feedings  disagree;  for 
infants  that  are  quite  sick  they  may  be  diluted  once  with  boiled  water. 

Making  Feedings  on  a  Large  Scale. — To  those  who  are  not  familiar 
with  methods  of  handling  milk  it  sometimes  becomes  a  difficult 
matter  to  work  out  the  proper  quantities  of  ingredients  to  use  to  get 
the  desired  formulas. 

By  referring  to  the  key  on  page  141,  the  required  percentage  of 
fat  in  milk  and  the  proportion  of  diluent  to  use  to  obtain  any  desired 
percentage  combination  will  be  found.  Thus,  if  a  mixture  containing 
0.80  per  cent,  protein  and  1  per  cent,  fat  was  desired,  it  would  be 
found  necessary  to  use  milk  containing  4  per  cent,  fat  wath  three  parts 
of  diluent.  If  1.5  per  cent,  fat  was  desired  with  0.80  per  cent,  protein, 
it  would  be  necessary  to  use  milk  containing  6  per  cent,  fat  with  three 
parts  of  diluent. 

On  a  small  scale  these  milks  can  be  readily  obtained  from  quart 
milk  bottles,  but  when  large  quantities  are  to  be  made  the  milks  must 
be  standardized. 

The  milk  should  be  obtained  from  a  farm  where  cleanliness  is 
observed,  and  it  should  be  kept  cool  until  delivered  at  the  central 
station  where  the  food  is  to  be  prepared.  A  sample  which  represents 
the  entire  lot  should  be  drawn,  by  dropping  a  long  tube  or  pipet 
through  the  milk  from  top  to  bottom  so  as  to  remove  a  sample  that 
represents  the  entire  can. 

This  is  then  tested  by  the  Babcock  milk  test,  which  consists  of, 
mixing  a  definite  quantity  of  the  milk  with  sulphuric  acid  in  a  special 
bottle  and  then  whirling  it  in  a  centrifuge.  Great  heat  is  produced 
which  melts  the  fat.  The  protein  dissolves  and  the  percentage  of  fat 
is  read  directly  from  the  neck  of  the  test  bottle.  The  milk  should' 
also  be  tested  with  lime-water  and  phenolphthalein  (page  131)  W 
see  if  souring  has  commenced.  :  .  i 


172  DISEASES  OF  CHILDREN. 

A  certain  amount  of  cream  or  skimmed  milk  will  always  be  needed. 
If  a  centrifugal  separator  is  available,  they  can  be  obtained  by  centri- 
fuging  the  milk.  Otherwise  the  cream  must  be  skimmed  by  hand 
from  a  can  of  the  whole  milk.  The  cream  and  remaining  milk  will 
also  have  to  be  tested  for  fat.  Knowing  the  percentage  of  fat  in  the 
whole  milk,  cream,  and  skimmed  milk,  it  becomes  necessary  to  calculate 
the  quantities  to  mix  to  make  any  standardized  milk. 

To  Increase  the  Amount  of  Fat  in  Milk. 

1.  Determine  the  quantity  of  standardized  milk  to  be  made,  it  may  be 
pounds,  quarts,  or  gallons. 

2.  Multiply  the  quantity  of  standardized  milk  by  its  percentage  of  fat. 
Example,  100  pounds  of  6  per  cent,  fat  milk,  100  X  6  per  cent.  =  600  per  cent. 

3.  Multiply  the  desired  quantity  of  standardized  milk  by  the  percentage  of 
fat  in  the  whole  milk  as  determined  by  the  Babcock  test,  as,  for  example,  100  pounds 

X  4.7  per  cent.  =  470  per  cent. 

4.  Subtract  the  amount  of  fat  in  the  quantity  of  whole  milk  from  the  amount 
of  fat  in  the  desired  quantity  of  standardized  milk,  to  find  how  much  fat  must 
be  added,  as  600  per  cent.  — 470  per  cent.  =  130  per  cent. 

5.  Determine  the  percentage  of  fat  in  the  cream,  as,  for  instance,  21  per  cent. 

6.  Subtract  the  percentage  of  fat  in  the  whole  milk  from  the  percentage  of 
fat  in  the  cream  to  find  how  much  fat  one  part  of  cream  contains  in  excess  of  that 
in  the  whole  milk.     Example,  21  per  cent.  — 4.7  per  cent.  =  16.3  per  cent. 

7.  Divide  the  additional  fat  required  by  the  amount  one  part  of  the  cream 
adds  to  find  how  many  parts  of  cream  must  be  used.  As,  130  per  cent,  h- 16.3 
per  cent.  =  8  parts. 

8.  Thus  8  pounds  of  cream,  21  per  cent,  fat,  and  92  pounds  of  milk,  4.7  per 
cent,  fat,  make  100  pounds  of  6  per  cent,  fat  milk. 

Proof:   8  X     21%    =    168% 
92  X     4.7%  =  432% 
100  600%  or  one  part  =  6%. 

To  Decrease  the  Amount  of  Fat  in  Milk. 

Proceed  as  in  1,  2,  and  3  above.  Then  divide  the  percentage  of  fat  in  the 
total  quantity  of  standardized  milk  desired  by  the  percentage  of  fat  in  the  whole 
milk.  For  example,  100  pounds  of  milk  containing  3  per  cent,  fat  were  needed,  and 
the  whole  milk  available  contained  4 . 7  per  cent.  fat.  100  X  3  =  300.  300-^4.7  per 
cent.  =  64  pounds.  By  adding  to  this  quantity  36  pounds  of  skimmed  milk 
there  will  be  produced  100  pounds  of  milk  containing  3  per  cent,  of  fat.  If  the 
skimmed  milk  contain  not  over  0.5  per  cent,  fat,  the  result  will  be  accurate  enough. 

After  standardized  milks  are  made,  great  care  must  be  exercised 
in  keeping  the  feeding  bottles  clean  and  in  washing  them,  for  all  the 
care  employed  in  preparing  the  milk  may  be  rendered  useless  by  water 
used  in  washing  bottles,  as  this  may  be  infected  and  produce  a  high 
bacterial  count  in  the  food. 


PRACTICAL  FEEDING.  173 

Feedings  Prepared  at  the  Feeding  Station. — When  a  physician  who 
thoroughly  understands  the  preparation  of  food  can  have  a  good 
nurse  to  carry  out  his  directions  and  with  only  two  rooms,  one  to  be 
used  as  a  kitchen  and  the  other  as  an  examining  room,  highly  sat- 
isfactory results  can  be  obtained.  The  physician  can  examine  the 
infant  and  order  any  kind  of  food  prepared,  and  the  nurse  will  prepare 
it  while  the  mother  waits.  The  food  is  put  up  in  nursing  bottles  and 
given  to  the  mother  in  a  box  or  pail  filled  with  cracked  ice.  By  using 
bottled  milk  and  the  Deming  Milk  Modifier,  percentage  mixtures  can 
be  quickly  made.  Gruel  mixtures,  whey,  or  whatever  is  desired  can 
also  be  made.  One  nurse  can  attend  to  about  thirty  infants  in  a 
morning. 


CHAPTER  XVH. 

DIET  DURING  THE  SECOND  YEAR. 

By  the  beginning  of  the  second  year  the  infant's  digestive  organs 
should  be  sufficiently  developed  to  warrant  giving  some  soft  food. 
The  greatest  amount  of  trouble  will  be  caused  by  cereals  which  are 
not  properly  cooked.     Fig.  56  shows  a  cross 
section  of  an  oat  grain.     It  will  be  observed 
that  the  protein  and  carbohydrates  are  in- 
closed in  cells.     These  are  composed  of  cellu- 
lose which  is  indigestible,  and  they  must  be 
raptured    by   cooking    before    the    digestive 
secretions  can  get  at  their  contents.     Fig.  57 
shows    what    takes   place  when   cereals   and 
vegetables  are  cooked  properly  and  too  much 
emphasis  cannot  be  laid  upon  the  importance 
of  thoroughly  cooking  cereals.     Oatmeal  par- 
ticularly should  be  cooked  in  a  double  boiler 
several  hours.     Flours  do  not  need  such  long 
cooking. 
The  following  schedule  has  been  arranged  as  a  suggestive  scheme 
for  the  feeding  of  older  normal  children: 


Fig.  56. — Section  of  oat 
grain,  c,  protein  layer; 
d,  starch  and  protein. 
(Goodale.) 


Fig.  57. — Rupture  of  starch  grains  by  cooking.     (Langworthy.) 

Many  children  are  indiscriminately  fed,  and  the  physician  being 
unfamiliar  with  the  kind  of  food  suitable  and  agreeable  to  the  child 
neglects  to  supply  directions  as  to  the  dietary.     Changes  should  be  made 

174 


DIET  DURING  THE  SECOND  YEAR.  175 

in  the  list  if  there  is  illness,  habitual  constipation,  or  difficulty  in  digest- 
ing certain  forms  of  food.  It  should  be  recollected  that  the  child  can  be 
trained  to  like  almost  every  suitable  article,  and  it  is  a  mistake  to  cater  to 
their  likes  and  dislikes  if  they  are  not  developing  and  gaining  weight. 
Under  their  respective  sections  changes  in  the  character  of  the 
food  have  been  suggested  where  they  have  any  bearing  on  the  progress 
of  the  disease.  ''OB^ff  1    rv 

Dietary.  "  ^    ^ORa    e_ 

Twelfth  to  Eighteenth  Month. — Select  from  the  following  articles :         " 

First  meal — on  arising. 

Juice  of  a  sweet  orange,  one  to  two  ounces. 

Pulp  of  six  stewed  prunes. 

Pineapple  juice,  one  ounce. 

Milk,  eight  ounces,  zwieback,  toasted  biscuits  (as  Huntley 

&  Palmer's),  stale  toasted  bread. 

Second  meal — during  forenoon. 
Milk  alone  or  with  zwieback. 

Noon  meal. 

Soup  made  of  chicken,  beef,  or  mutton,  six  ounces;  or  beef 

juice  three  ounces.     Stale  or  toasted  bread  may  be  added  to 

the  above. 
Fourth  meal — afternoon. 

Milk,  or  toasted  bread  and  milk. 
Evening  meal. 

Gruel  made  of  oatmeal,  farina  or  barley,  taken  with  whole 

milk,  four  ounces  of  each. 

Apple  sauce  or  prune  jelly. 

Zwieback. 

Eighteenth  to  the  Twenty -fourth  Month. 

Breakfast. 

Juice  of  one  sweet  orange. 

Pulp  of  six  stewed  prunes. 

Pineapple  juice,  one  ounce. 

A  cereal,  such  as  cream  of  wheat,  oatmeal,  farina,  or  hominy 

preparations  with  top  milk  (top  16  oz.).     Sweetened  or  salted. 

A  glass  of  milk. 

Forenoon. 

A  glass  of  milk  with  two  toasted  biscuits  or  zwieback. 


176  DISEASES  OF  CHILDREN. 

Dinner. 

Broth  or  soup  made  of  beef,  mutton,  or  chicken  and  thickened 

with  peas,  farina,  sago  or  rice;  or  beef  juice  with  stale  bread 

crumbs;  clear  vegetable  soup  with  yolk  of  one  egg;  or  egg, 

soft  boiled,  with  bread  crumbs,  or  the  egg  poached. 

A  glass  of  milk. 

Dessert. — Apple  sauce,   prune  pulp,   stale  lady-fingers,   or 

graham  wafers. 

Supper. 

Custard.     Cup  of  milk  warm  or  cold.     Stewed  fruit.     Zwie- 
back. 


Two  to  Three  Years. 

Breakfast. 

Juice  of  one  sweet  orange;  pulp  of  six  st  ewed  prunes. 

Pineapple  juice,  one  ounce,  or  apple  sauce. 

A  cereal,  such  as  oatmeal,  farina,  cream  of  wheat,  hominy, 

or  rice,  slightly  sweetened  or  salted  as  preferred,  with  the 

addition  of  top  milk  (top  16  oz.);  or  a  soft-boiled  or  poached 

egg  with  stale  bread  or  toast. 

(If  there  is  a  tendency  to  constipation  give  the  fruits  before 

breakfast  with  water;  if  not,  they  may  be  given  during  the 

forenoon  if  preferred.) 

A  glass  of  milk. 

Dinner. 

Broth  or  soup  made  of  chicken,  mutton,  or  beef  thickened 

with  arrowroot,  split  peas,  rice,  or  with  the  addition  of  the 

yolk  of  an  egg  or  toast  squares. 

Scraped  beef,  white  meat  of  chicken,  broiled  fish  (halibut  is 

free  from  bones). 

Mashed  or  baked  potato,  fresh  peas,  spinach,  asparagus  tips. 

A  glass  of  milk  with  educator  crackers,  Huntley  &  Palmer 

biscuits  or  graham  wafers. 

Dessert. — Apple  sauce,  baked  apple,  rice,  junket,  or  custard. 

Supper.  , 

Stewed  fruit. 

A  cereal  or  egg  (if  not  taken  for  breakfast);  bread  and  milk; 
or  custard;  cup  of  warm  milk  or  cocoa;  crackers  or  zwieback. 


DIET  DURING  THE  SECOND  YEAR.  177 

Three  to  Six  Years. 

Breakfast. 

Fruits. — Oranges,  cantaloupe,  apples,  or  stewed  prunes. 
Cereal  or  eggs  (not  both).     Oatmeal,  hominy,  rice  and  wheat 
preparations,  well  cooked  and   salted,  as  described  on  page 
174,  with  thin  cream  and  sugar. 
Eggs. — Soft  boiled,  poached. 
Milk. — Milk  or  cocoa  to  drink. 


Dinner. 


Supper. 


Soups. — Beef,  chicken,  or  mutton. 

Meat. — Chicken,  beefsteak  or  roast  beef,  fish. 

Vegetables. — Spinach,  carrots,  string  beans,  peas,  cauliflower 

tops,  mashed  or  baked  potato,  asparagus  tips. 

Bread  and  butter  (not  fresh  bread  or  rolls). 

Dessert. — Custard,  rice  or  bread  pudding,  tapioca,  ice  cream 

(once  a  week),  prune  souffle,  or  baked  apple. 

Milk. 

Milk  toast,  or  a  thick  soup,  as  pea,  or  cream  of  celery,  or  a 
cereal  and  thin  cream.  Stewed  fruit,  custard  or  a  plain  pud- 
ding gra,ham  crackers  and  milk. 


Suggestive  Diet  List  Suitable  for  Children's  Hospitals. 

Monday. 

Breakfast. — Oatmeat,  bread  and  butter,  milk. 

Dinner. — Beef  soup,   chicken,   mashed  potatoes,   bread  and  butter, 

corn  starch  pudding,  milk. 
Supper. — Bread  and  butter,   milk,  apple  sauce. 

Tuesday. 

Breakfast. — Eggs,  bread  and  butter,  milk. 

Dinner, — Chicken  soup,   chicken,  mashed  potatoes,  bread  and  butter, 

rice  pudding,  milk. 
Supper. — Bread  and  butter,  milk,  stewed  prunes. 

Wednesday. 

Breakfast. — Hominy,  bread  and  butter,  milk. 

Dinner. — Beef  soup,  roast  beef,  mashed  potatoes,  bread  and  butter, 

bread  pudding,  milk. 
Supper. — Bread  and  butter,  jam,  and  milk. 
12 


178  DISEASES  OF  CHILDREN. 

Thursday. 

Breakfast. — Eggs,  bread  and  butter,  milk. 

Dinner. — Beef  soup,  chicken,  mashed  potatoes,  bread  and  butter,  ice 

cream,  milk. 
Supper. — Bread  and  butter,  jam,  and  milk. 

Friday. 

Breakfast. — Oatmeal,  bread  and  butter,  milk. 

Dinner. — Mutton  broth,  roast  mutton,  mashed  potatoes,  bread  and 

butter,  custard  pudding,  milk. 
Supper. — Bread  and  butter,  milk,  apple  sauce. 

Saturday. 

Breakfast. — Hominy,  bread  and  butter,  milk. 

Dinner. — Beef  soup,  roast  beef,  mashed  potatoes,  bread  and  butter, 

chocolate  pudding,  milk. 
Supper. — Bread  and  butter,  milk,  stewed  prunes. 

Sunday. 

Breakfast. — Oatmeal,  bread  and  butter,  milk. 

Dinner. — Beef  soup,  roast  beef,  mashed  potatoes,  bread  and  butter, 

ice  cream,  milk. 
Supper. — Bread  and  butter,  milk,  jelly. 

Suggestive  Diet  Lists  for  Day  Nurseries  and  Crfeches. 
Group  1  (Bottle- weaned  babies). 

Milk  (whole  milk),  warm  or  cold,  8  ounpes. 

Farina  gruel  with  milk  and  sugar,  zwieback. 

Beef  or  mutton  soup,  thickened  with  toast  crumbs. 

Orange  juice,  1  ounce. 

Apple  sauce. 

Prune  pulp. 

Amount  needed  daily — three  meals —  24  ounces  milk,  10  ounces 

soup,  zwieback,  2  pieces,  fruit,  one  kind. 

Group  2  ("Runabouts")- 

Milk. 

Zwieback  or  toast,  or  stale  bread. 

Soft-boiled  egg. 

Farina,  cream  of  wheat,  oatmeal. 


DIET  DURING  THE  SECOND  YEAR.  179 

Soup,   beef  or  mutton  thickened  with  spHt  peas,   rice,    or 

farina. 

Baked  potato,  mashed  potato,  carrots,  beets. 

Custard,    cornstarch,    farina   pudding,    apple   sauce,    prune 

jelly,  or  apple  butter. 

Amount  required  daily,  three  meals,  36  ounces  of  milk,  one 

cereal,  one  vegetable,  one  soup,  bread,  one  fruit. 

Group  3  (Kindergartners — two  meals). 

Bowl  of  crackers  and  milk,  farina,  oatmeal. 

Beef  or  mutton  stew. 

Eggs,  soft-boiled  or  scrambled. 

Mashed  potato,  peas,  carrots,  beets,  cauliflower. 

Rice  pudding,  cornstarch  pudding,  baked  apple,  apple  sance, 

prunes. 

Amount   required,  three  cups   milk,  soup,  vegetable,  bread 

and  butter,  cereal  or  pudding. 

Group  4  (School  age). 

Noon. 

Soup, beef  or  mutton. 

Beef  or  mutton  stew. 

Potato  (mashed),  spinach,  carrots,  or  beets. 

Bread  and  butter. 

Pudding,  farina,  rice,  cornstarch. 
4  p.  M. 

Milk,  cocoa. 

Bread  and  butter,  jam. 

Raw  apples. 

Diet  During  Later  Childhood. 

The  period  of  growth  from  early  childhood  to  puberty  requires 
careful  oversight  of  the  nutrition.  The  child  must  be  regularly  trained 
in  all  the  hygienic  details  of  feeding,  including  slow  eating  and  the 
avoidance  of  strenuous  exercise  just  before  or  after  eating.  The  diet 
requires  a  large  amount  of  protein  owing  to  the  rapid  growth,  and  this 
must  be  supplied  principally  by  the  ordinary  meats  (beef,  mutton, 
and  chicken)  and  such  vegetables  as  peas  and  beans.  All  the  cereals 
will  also  supply  some  protein  with  a  large  amount  of  starch.  The 
heat-  and  energy-producing  foods  (starches,  sugars,  and  fats)  may  be 
supplied  in  the  form  of  potatoes,  cereals,  fruits,  and  fats  from  milk 


180  DISEASES  OF  CHILDREN. 

or  meat.  It  is  very  desirable  to  train  the  child  to  take  a  varied  and 
properly  balanced  diet,  which  includes  all  the  foods  in  common  use. 
Thus  if  very  much  meat  is  taken  to  the  exclusion  of  carbohydrates,  the 
protein  will  be  employed  too  largely  in  oxidation  to  produce  body  heat 
instead  of  in  building  tissue,  and  hence  growth  may  be  retarded.  A 
certain  amount  of  the  carbohydrates  acts  as  protein  sparers,  and 
thus  allows  the  protein  to  be  used  entirely  in  its  proper  function  of 
building  tissue.  This  is  an  example  of  the  desirability  of  a  properly 
balanced  diet.  The  green  and  succulent  vegetables  and  fruits  also 
have  an  important  function  in  nutrition,  as  is  seen  in  cases  of  scorbutus 
where  there  has  been  a  long  deprivation  of  these  articles  of  diet. 
Lesser  degrees  of  malnutrition  result  if  they  are  not  taken  in  proper 
amount. 

The  two  usual  cycles  of  growth,  namely  at  the  second  dentition 
and  adolescence,  require  an  especially  generous  diet.  Rapid  growth 
always  uses  up  nutrient  material  and  hence  calls  for  food,  rich  in 
protein,  otherwise  various  grades  of  anemia  are  liable  to  result. 


SECTION  V. 
DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


CHAPTER  XVIII. 
DISEASES  OF  THE  MOUTH. 

General  Considerations. 

It  is  very  essential  that  the  normal  condition  of  the  mouth  be 
preserved  in  infancy,  as  the  act  of  sucking  may  be  impaired  and  thus 
result  in  malnutrition  of  the  infant.  The  mucous  membrane  of  the 
mouth  is  particularly  delicate,  and  bacterial  invasion  follows  readily 
any  injury  to  its  surface.  Even  well-meant  but  too  vigorous  cleansing 
by  the  attendant  may  lead  to  serious  mouth  disease.  Not  until  the 
teeth  are  present  should  any  special  effort  be  made  to  cleanse  the  oral 
cavity.  The  primary  teeth  should  receive  regular  attention,  and  the 
aim  should  be  to  preserve  them  as  long  as  possible,  and  thus  ensure  a 
vigorous  and  well-formed  permanent  set.  A  soft  tooth-brush,  used 
with  an  up-and-down  movement,  will  effectively  cleanse  the  teeth  from 
adhering  particles  of  food,  especially  if  the  child  learns  to  flush  or 
gargle  the  mouth  after  its  use. 

The  nodules  formed  near  the  raphe  in  infants  are  normal  cystic 
bodies  called  epithelial  pearls,  and  must  not  be  considered  pathological. 
We  have  seen  harm  done  by  measures  used  for  their  removal. 

Desquamative  Glossitis. 

{Geographic  Tongue.  Ringworm  of  the  Tongue.) 
The  above  headings  apply  to  a  condition  of  the  tongue  in  which 
there  are  areas  sharply  circumscribed  by  sinuous  borders.  The  bor- 
ders are  made  up  of  enlarged  papillae  of  a  dull  grayish  color  which  tend 
to  intensify  the  denuded  areas.  Numerous  microorganisms  of  a  low 
order  are  found  especially  in  the  borders  of  the  patches.  The  varia- 
tions in  the  outlines  have  given  rise  to  the  term  "  geographical  tongue." 
It  is  found  among  all  classes  of  children;  it  can  only  occasionally  be 
associated  with  the  derangement  of  the  digestive  tract.  It  gives  no 
symptoms,  and  is  productive  only  of  alarm  to  the  mother.  It  is  most 
commonly  seen  in  children  under  three  years  of  age. 

Treatment. — The  mother  should  be  reassured  as  to  its  unimpor- 
tance. Nitrate  of  silver,  J  dram  to  the  ounce,  applied  with  a  cotton 
swab  and  neutralized  with  a  salt  solution  has  seemingly  arrested  the 

181 


182  DISEASES  OF  CHILDREN. 

process  in  a  few  cases.     In  others  it  has  persisted  for  months,  only  to 
finally  disappear  spontaneously. 

Simple  Stomatitis. 

(Catarrhal  Stomatitis). 

Simple  stomatitis  is  an  inflammation  of  the  mucous  membrane  of 
the  mouth,  with  the  characteristic  symptoms  of  pain,  redness,  and 
swelling,  and  an  increase  in  the  normal  amount  of  secretion. 

Etiology. — It  is  mainly  observed  in  the  first  year  of  life,  and  re- 
sults from  some  form  of  irritant,  which  may  be  chemical,  mechanical, 
or  thermal  in  its  nature.  Among  those  commonly  causative  are  im- 
properly prepared  food,  thumb  or  nipple  sucking,  and  too  vigorous 
mouth  washing.  Excessive  use  of  carbohydrates,  especially  cane- 
sugar,  may  be  a  cause,  and  the  disease  is  occasionally  an  accompani- 
ment of  prolonged  fever  due  to  intercurrent  maladies. 

Symptomatology. — The  babe  refuses  to  take  its  nourishment  or 
has  pain  while  taking  it.  This  should  direct  attention  to  the  mouth. 
There  is  marked  drooling,  and  on  inspection,  redness,  swelling  and 
congestion  of  the  mucous  membrane  are  apparent.  The  tongue  may 
be  more  or  less  coated.  The  temperature,  if  elevated  at  all,  is  not 
high.  There  is  no  adenitis.  The  restlessness  and  irritability  point  to 
a  constitutional  involvement. 

Treatment. — The  afifection  tends  to  a  spontaneous  recovery,  es- 
pecially if  the  causative  factor  is  removed.  After  a  few  days  there 
is  restitution  to  normal  conditions.  Prophylactic  treatment  embraces 
the  constant  care  and  cleanliness  of  everything  coming  into  contact 
with  the  child's  mouth.  On  the  other  hand,  we  have  observed  the 
inflammation  following  well-meant  but  too  vigorous  mouth  cleansing. 
Local  applications  hasten  recovery.  A  1  per  cent,  solution  of  nitrate 
of  silver  may  be  brushed  over  the  surface  by  the  physician  once  a  day, 
and  a  2  per  cent,  solution  of  boric  acid  is  swabbed  on  every  two 
hours  by  the  attendant. 

The  following  is  an  excellent  and  soothing  lotion  for  all  forms  of 
sore  mouth: 

I^    Sodii  sulphis 5 j 

Glycerini 3ss 

Aquae  rosae q.s.  ad.  5ij 

M.  Sig. — Paint  over  the  tongue  and  inside  of  the 
cheeks  every  two  or  three  hours  with  a  camel's-hair 
brush. 

Order  the  food  diluted  one-half  and  given  cold.     If  the  nipple  is 

refused  in  an  artificially  fed  baby,  feed  with  the  spoon  or  dropper. 

It  is  rarely  necessary  to  resort  to  gavage. 


DISEASES    OF   THE   MOUTH.  183 

Aphthous  Stomatitis. 

(Herpetic  Stomatitis,  Aphthce,  Follicular  Stomatitis,  Vesicular 
Stomatitis,  Maculo fibrinous  Stomatitis.) 

Definition. — A  disease  characterized  by  isolated  yellowish-white 
spots  on  the  lips,  mouth,  or  palate,  surrounded  by  a  reddened  mucous 
membrane. 

Etiology. — No  specific  exciting  cause  has  as  yet  been  firmly  estab- 
lished. The  weight  of  evidence  seems  to  point  to  an  infective  rather 
than  to  a  neurotic  origin,  since  clinically  we  have  found  its  spread 
possible  through  communication.  Lack  of  proper  cleanliness  is  the 
cause  in  the  great  majority  of  cases.  Most  of  the  attacks  occur  dur- 
ing the  second  year  of  life;  and  we  have  in  addition  to  uncleanliness 
of  the  mouth  and  utensils,  the  direct  dirt  infection  produced  by  the 
crawling,  hand-sucking  infant.  It  is  also  seen  occasionally  in  connec- 
tion with  such  diseases  as  pneumonia,  gastroenteritis,  or  the  infectious 
diseases  proper. 

Lesion. — The  superficial  mucous  membrane  shows  a  fibroplastic 
exudate  in  a  localized  area,  having  a  reddened  areola.  The  process 
does  not  go  on  to  ulceration,  the  mucous  membrane  healing  without 
scar  formation. 

Symptomatology. — Before  the  lesions  are  observed  it  may  be 
noted  that  food  is  refused  or  taken  with  discomfort  by  the  infant. 
The  pain  causes  irritability  and  disturbed  sleep.  There  is  sometimes 
a  low  febrile  reaction.  The  breath  is  not  foul.  The  saliva  flows 
freely.  After  a  few  days  the  glands  beneath  the  jaw  may  be  somewhat 
enlarged  and  painful  to  the  touch.  Inspection  shows  a  number  of 
whitish  spots,  which  sometimes  coalesce,  on  the  lips,  cheeks,  or  palate, 
surrounded  by  a  red  ring.  The  pseudomembrane  cannot  be  removed 
without  exciting  some  slight  bleeding. 

Course  and  Prognosis. — The  affection  lasts  about  a  week  and  tends 
to  recovery.  With  proper  treatment  the  course  is  considerably 
shortened. 

Treatment. — Prophylactic.  This  embraces  all  that  was  said 
under  simple  stomatitis,  and  may  be  stated  in  one  word — cleanliness. 

Local. — The  early  application  of  a  2  per  cent,  solution  of  silver 
nitrate,  once  or  twice  daily,  shortens  the  disease  and  makes  the  infant 
much  more  comfortable.  A  2  per  cent,  solution  of  chlorate  of  potash 
may  be  applied  by  the  attendant  three  times  a  day  with  a  brush. 

General. — A  dose  of  castor  oil  is  usually  indicated  and  helpful. 
The  diet  should  comprise  cool  milk  or  gruels  until  the  discomfort  has 
disappeared. 


184  DISEIASES  OF  CHILDREN. 

Bednar's  Aphthae. 

These  are  superficial  ulcerations  which  occur  in  the  new-born  or  in 
early  infancy  on  either  side  of  the  palatine  ridge  at  the  hamular 
process.  They  are  usually  the  result  of  traumatism  caused  by  too 
energetic  cleansing  or  the  sucking  of  artificial  nipples.  This  portion 
of  the  mucous  membrane  is  normally  thin  and  tightly-stretched,  and 
therefore  easily  abraded.  Not  infrequently  these  ulcerations  are  seen 
following  thrush.  They  are  usually  bilateral,  about  the  size  of  a  small 
bean,  and  are  covered  with  a  grayish-white  necrotic  coating  which 
cannot  easily  be  washed  away.  Nursing  is  interfered  with  on  account 
of  the  pain  they  cause. 

Treatment. — ^Prophylactic. — The  proper  care  of  the  infant's  mouth 
(see  p.  182)  and  the  early  treatment  as  in  thrush. 

Locally. — The  application  daily  of  a  2  per  cent,  solution  of  silver 
nitrate,  which  is  neutralized  by  salt  solution,  will  readily  effect  a  cure. 

Perleche. 

This  is  an  ulcerative  process  superficial  in  character  which 
appears  at  the  angle  of  the  mouth  of  children  of  school  age. 

Radiating  fissures  first  appear  at  the  corners  of  the  mouth  which 
are  brownish-yellow  in  color,  and  soon  become  covered  with  desqua- 
mating epithelium.  A  gummy  exudate  contracts  the  angles  which 
readily  bleed  if  stretched.  Licking  the  lips,  no  doubt,  infects  these 
areas,  and  prevents  healing.  Contamination  to  others  in  the  family  is 
occasionally  observed. 

Treatment. — Proper  advice  as  to  contact  infection  by  kissing, 
food  utensils,  etc.,  is  to  be  given. 

Locally,  the  area  is  thoroughly  cleansed  and  swabbed  with  silver 
nitrate  2  per  cent,  or  burnt  alum.  An  antiseptic  powder  such  as 
bismuth  subgallate  may  then  be  applied. 

Mycotic  Stomatitis. 

(Parasitic  stomatitis,  Thrush,  Sprue,  Soor,  White  Mouth.) 

Definition. — This  is  a  local  mouth  disease  produced  by  the  growth 
of  a  specific  cryptogamic  fungus. 

The  affection  occurs  most  frequently  in  early  infancy.  The 
children  of  the  poor,  because  of  parental  ignorance  or  neglect,  are 
prone  to  the  disease.  Badly  or  improperly  fed  infants  are  subject 
to  this  affection  because  of  the  greater  liability  to  uncleanliness  in  the 
feeding  apparatus.      Marasmic  and  atrophic  infants  seen  in  hospital 


DISEASES  OF  THE  MOUTH.  185 

and  dispensary  practice,  seldom  pass  through  the  first  few  months  of 
Ufe  without  contracting  the  disease. 

Specific  Cause. — Under  the  microscope  a  small  particle  of  the 
growth  appears  as  a  matted  fungus  microorganism,  made  up  of 
shreads,  composed  of  jointed  filaments.  Spores  are  found  at  the 
junction  of  the  filaments,  which  reproduced  the  growth.  This  par- 
ticular fungus  has  not  as  yet  been  properly  classified. 

Symptomatology. — Small  rounded  white  masses  appear  on  the 
mucous  membrane  of  the  mouth.  The  tip  of  the  tongue,  and  next  the 
cheeks  and  gums  are  affected.  In  exceptional  instances  remoter 
areas  of  the  gastrointestinal  tracts,  as  the  esophagus  and  stomach, 
are  involved. 

As  the  masses  fuse,  the  characteristic  appearance,  i.e.,  a  whitish 
coating  resembling  milk  curd,  is  seen  in  the  mouth. 

The  masses,  if  an  attempt  is  made  at  removal,  come  away  with 
difiiculty,  leaving  a  reddened  surface  beneath.  As  the  disease  pro- 
gresses, the  infant  has  difficulty  in  feeding  and  will  be  restless  and 
peevish.  There  is  rarely  any  constitutional  disturbance  or  rise  of 
temperature.  Occasionally  there  will  be  concomitant  irritation  of 
the  alimentary  tract  with  the  production  of  vomiting  and  abnormal 
stools.  If  the  reaction  of  the  mouth  be  taken  with  litmus-paper  it 
will  invariably  be  found  acid  in  reaction.  Exfoliation  of  the  pellicles 
take  place  after  a  week  or  ten  days,  leaving  the  mucous  membrane 
reddened  and  glistening. 

Course  and  Prognosis. — The  affection  lasts  from  a  few  days  to  a 
week  at  the  most.  The  exceptions  appear  in  infants  with  constitutional 
diseases  in  which  thrush  appears  as  a  complication;  in  these  it  may 
persist  for  a  long  time  or  add  to  the  fatality  of  the  case. 

Treatment. — Prophylactic. — Thrush  does  not  appear  in  those 
infants  who  have  been  properly  cared  for.  The  essential  prophy- 
lactic measures  are  constant  supervision  and  great  cleanliness  of  the 
infant's  utensils,  which  should  be  boiled  and  kept  for  the  one  infant 
only;  washing  the  mother's  nipples,  avoidance  of  harsh  mouth  wash- 
ings, removal  of  soiled  clothes  and  diapers,  and  absolute  restriction 
of  all  manner  of  comforters  or  soothers.  The  diet  must  be  carefully 
regulated,  as  infants  suffering  from  this  disease  have  nearly  always 
been  wrongly  fed.     (See  section  on  Infant  Feeding.) 

Local. — Swab  with  a  2  per  cent,  or  a  saturated  solution  of  boric 
acid  (avoid  the  honey  and  boric  preparations),  three  or  four  times 
a  daj'',  and  follow  with  copious  washing  of  sterile  water.  This  is 
curative  and  soothing.  In  stubborn  cases  swab  once  with  a  weak  for- 
malin solution  (1-100)  and  then  use  the  boric  wash.     Sodium  sul- 


186  DISEASES  OF  CHILDREN. 

phite  dram  one  to  two  ounces  of  water  may  be  used  after  each  feeding. 
If  the  nipple  is  refused,  feed  with  a  dropper  for  a  few  days. 

Ulcerative  Stomatitis. 
(Stomacacce,  Putrid  sore  mouth.) 

Etiology. — This  form  of  stomatitis  is  found  after  the  second  year 
of  life,  when  the  teeth  have  erupted  and  caries  or  neglect  of  the  teeth 
has  taken  place.  It  follows  the  infectious  diseases,  especially  measles, 
and  results  from  the  lowered  resistance  that  the  previous  disease  has 
imposed.  Bernhem  and  Pospisil  have  isolated  a  bacillus  and  a  spiro- 
chsBte,  which  they  find  quite  constantly  in  ulcerative  stomatitis,  and 
they  have  been  able  to  prove  a  distinct  etiological  relation.  Minerals, 
such  as  mercury  and  phosphorus,  are  able  to  produce  an  ulcerative 
stomatitis  through  their  irritative  action. 

Symptomatology. — Attention  may  be  attracted  to  the  child  be- 
cause food  is  refused  and  pain  is  caused  by  attempts  at  eating.  The 
breath  is  foul.  The  tongue  is  coated.  The  children  are  irritable  and 
sleep  poorly.  There  is  a  low-grade  temperature.  They  become  weak 
and  depressed  from  lack  of  food.  The  examination  of  the  mouth  shows 
the  gums  at  first  to  be  swollen  and  red.  The  lower  jaw  is  commonly 
involved  at  some  point  situated  on  the  edge  of  the  gums.  A  purulent 
exudate  is  then  formed  that  goes  on  to  necrosis  and  the  formation  of 
an  ulcer.  As  a  rule,  the  preliminary  stages  are  not  observed.  An 
ulceration  on  the  gum  margin  which  spreads  even  to  the  buccal  por- 
tion of  the  gum  is  the  usual  picture.  In  aggravated  cases  the  tooth  is 
exposed  and  loosened  in  its  socket.  The  odor  is  distinctly  fetid  and 
quite  characteristic  of  this  form  of  mouth  disease.  Drooling  is  pro- 
nounced. The  cheek  and  lips  may  also  be  involved  by  contact,  and 
even  necrosis  of  the  jaw  may  follow  in  the  pathological  process.  The 
neighboring  lymph-glands  become  hypertrophied. 

Course  and  Prognosis. — The  prognosis  depends  greatly  upon  the 
vitality  of  the  child.  In  poorly  nourished,  anemic  children,  it  may 
run  an  obstinate  course  of  several  weeks.  As  a  rule,  it  begins  to  clear 
up  after  the  first  week. 

Differential  Diagnosis. — The  almost  typical  picture,  with  the  fetid 
breath,  salivation,  and  localization  on  the  gums,  stamps  the  disease 
quite  clearl5^  In  gangrenous  stomatitis  we  have  marked  and  early 
constitutional  symptoms  and  prostration,  with  a  limited  dark,  pur- 
plish area  of  tissue  involved. 

Treatment,  Local. — The  mouth  should  at  once  be  carefully  flushed 
with  a  mild  antiseptic,  such  as  boric  acid  or  peroxid  of  hydrogen  well 


DISEASES  OF  THE  MOUTH.  187 

diluted.  Remove  the  offending  carious  tooth  if  present,  and  then  use 
chlorate  of  potash  locally  (and  also  internally,  see  below),  four  grains 
to  the  ounce,  applied  carefully  with  a  brush  or  cotton  applicator. 
Silver  nitrate  in  a  1  per  cent,  solution  locally,  is  serviceable,  if  the 
process  is  obstinate.  If  necrosis  of  bone  has  taken  place,  surgical 
intervention  is  necessary  and  should  not  be  delayed. 

General. — The  nutrition  should  be  rigidly  kept  up  and  detailed 
feeding  lists  supplied.  Milk  and  eggs  made  palatable  (see  diet 
lists)  should  be  forced  if  necessary.  An  antiscorbutic  diet,  such  as 
is  described  under  infantile  scorbutus  is  particularly  serviceable  in 
these  cases.  Medicinal  treatment  is  confined  to  the  use  of  the  chlorate 
of  potash  in  2-  to  3-grain  doses,  three  or  four  times  a  day.  It  is  better 
not  to  write  for  more  than  a  three-ounce  mixture,  as  the  potash  may 
affect  the  kidneys  if  given  for  too  long  a  period. 

Gangrenous  Stomatitis. 

(Noma,  Cancrum  oris.) 

Definition. — A  rapidly  developing  and  usually  fatal  gangrene, 
beginning  in  the  cheek. 

Etiology. — No  specific  organism  has  as  yet  been  satisfactorily 
proven  as  the  causative  agent.  The  disease  occurs  in  children  only, 
most  often  between  the  ages  of  two  and  five  years  and  rarely  in  nurs- 
lings. Children  living  in  bad  hygienic  circumstances  that  have  had 
their  resistance  much  lowered  by  previous  diseases,  especially  those 
that  have  been  confined  to  hospitals  and  asylums,  are  more  prone  to 
the  affection.  It  may  follow  measles,  diphtheria,  typhoid,  ulcerative 
stomatitis,  scarlet  fever,  enteritis,  pneumonia,  pertussis,  tuberculosis, 
etc.  The  greater  number  of  cases  occurring  in  this  country  have 
followed  severe  cases  of  measles,  and  in  the  epidemic  form  in  institu- 
tions, it  may  there  even  follow  mild  cases. 

Symptomatology. — A  putrid  odor  from  the  mouth  may  be  the 
first  symptom  to  attract  attention.  Inspection  may  then  disclose  a 
stomatitis  as  a  forerunner.  In  other  cases  there  is  first  observed  a 
swelling  of  the  cheek,  which  is  hard,  shining,  and  pallid.  Pain  is  not 
caused  by  the  examining  finger.  The  inner  surface  of  the  cheek  may 
show  the  original  site  of  the  infiltration  and  at  this  point  an  ulceration 
is  observed.  The  submaxillary  glands  if  not  as  yet  affected  soon 
hypertrophy.  The  infiltrated  area  in  the  cheek  now  becomes  dark 
red,  and  soon  is  bluish  and  later  black  in  color.  The  fetor  increases. 
A  line  of  demarcation  now  appears  about  the  dark  area  and  spreads 
upward  to  the  eye  and  outward  toward   the   ear.     A   punched-out 


188  DISEASES  OF  CHILDREN. 

area  soon  appears,  permitting  inspection  into  the  mouth.  The  gums 
are  correspondingly  affected,  being  covered  with  greenish-gray  slough. 

The  periosteum  may  be  separated.  The  teeth  are  loosened  or 
even  drop  out.  There  is  seldom  any  bleeding  because  the  process  is  a 
gangrenous  one.     The  stench  is  now  almost  intolerable. 

As  may  be  supposed  the  general  condition  soon  suffers  from  such 
a  destructive  process.  The  pulse  and  temperature  are  elevated — 102° 
to  104°  F. — with  a  correspondingly  weak  pulse. 

While  at  first  nourishment  is  taken  and  little  pain  complained 
of,  soon  the  patient  succumbs  and  is  badly  prostrated.  Signs  of 
exhaustion  are  apparent.  Patches  of  bronchopneumonia  or  a 
diarrhea  complicate  the  disease.  A  comatose  condition  with  septic 
rises  of  temperature  usher  in  the  fatal  ending. 

In  certain  cases  in  female  infants  the  necrosis  involves  the  vulval 
ring  which  may  soon  completely  slough  out. 

Course  and  Prognosis. — The  course  is  rapid;  the  dised,se  may  end 
in  a  week  or  last  three  weeks  from  its  inception.  Only  15  per  cent, 
of  the  cases  recover  (Moro).  Those  that  do  live  are  left  with  severe 
deformities  of  the  face. 

Treatment. — Strict  attention  to  the  nasopharyngeal  toilet  in  the 
infectious  diseases  will  tend  to  prevent  this  affliction. 

The  early  and  complete  extirpation  of  the  diseased  area  and 
cauterization  of  the  edges  is  the  modern  treatment  adopted  by  the 
surgeons,  and  the  results  achieved  warrant  its  recommendation. 
Wherever  possible,  attempts  should  be  made  to  save  the  angle  of  the 
mouth  to  prevent  a  disastrous  deformity.  Loosened  teeth  or  necrotic 
alveolar  structure  should  be  removed. 

Meanwhile,  the  internist  will  flush  the  mouth  with  a  2  per  cent, 
solution  of  peroxid  of  hydrogen,  or  swab  with  a  5  per  cent,  solution  of 
nitrate  of  silver,  followed  by  salt  solution. 

Nourishment  should  be  forced  and  stimulation  in  the  form  of 
brandy  and  strychnia  given.  Turpentine  spirits,  if  kept  near  the 
patient,  will  mitigate  the  nauseating  odor. 

Elongated  Uvula. 

Although  rarely  observed,  this  condition  has  led  to  much  improper 
medication  for  persistent  cough.  Th.e  elongated  uvula  irritates  the 
pharynx  and  causes  a  cough  which  is  especially  marked  when  the 
prone  position  is  assumed  or  when  the  child  is  overtired.  ■  If  the 
chest  is  negative,  this  condition  should  be  thought  of.  Treatment  is 
by  astringents,  applications  of  silver  nitrate,  but  usually  amputation 
is  indicated  and  necessary. 


CHAPTER  XIX. 
DISEASES  OF  THE  DIGESTIVE  TRACT. 

Corrosive  Esophagitis. 

Etiology. — This  condition  is  caused  by  the  swallowing  of  caustic 
chemicals,  such  as  potash  and  sulphuric  acid,  which  produce  corrosive 
burns  of  the  esophagus.  Lye  is  the  most  common  substance  ingested 
by  children.  The  lesions  vary.  There  may  be  an  intense  acute  inflam- 
mation, a  necrosis  of  the  mucous  membrane,  or  extensive  ulcerations 
which  produce  cicatricial  strictures  in  healing. 

Symptomatology. — If  much  caustic  has  been  swallowed,  death 
may  shortly  result;  otherwise  there  is  prostration  and  vomiting  of 
shreds  of  bloody  mucus,  or  even  pieces  of  mucous  membrane  may  be 
expelled.  The  child  cannot  swallow  without  pain.  An  erosive  hemor- 
rhage may  occur  after  a  day  or  two,  or  a  deep-seated  cellulitis  may 
result  with  infection.  A  stricture  is  very  likely  to  develop  in  severe 
cases. 

Treatment. — Appropriate  antidotes  are  to  be  given  if  the  patient 
is  seen  early;  such  as  the  acids  or  the  alkalies,  depending  on  the 
character  of  the  poison.  The  prostration  must  be  combated  by 
supportive  treatment,  hypodermatic  injections  of  camphor  or  strych- 
nia. For  the  intense  pain,  codein  subcutaneously  will  be  indicated. 
Olive  oil  thrown  into  the  esophagus  is  a  distinct  advantage,  and  if 
the  child  can  swallow,  this  should  be  regularly  administered.  The 
treatment  of  the  stricture  is  surgical.  The  string  method  has  given 
some  brilliant  results  in  cases  coming  under  our  observation.  Gas- 
trostomy may  be  necessary  to  preserve  the  life  of  the  child  if  sudden 
occlusion  of  the  esophagus  results. 

Congenital  Occlusion  of  the  Esophagus. 

This  condition  is  rarely  observed.  Difficulty  in  swallowing  and 
the  regurgitation  of  the  smallest  quantities  of  food  should  lead  to  an 
investigation  with  the  bougie.  The  atresia  or  stricture  is  usually 
situated  at  or  near  the  bifurcation  of  the  larynx. 

189 


190  DISEASES  OF  CHILDREN, 

(Acute  Gastric  Indigestion. 

Acute  gastritis,  acute  dyspepsia ,  acute  gastric  catarrh.) 

Etiology. — Errors  in  diet  are  the  principal  cause.  In  infancy  the 
quality  and  quantity  of  the  milk,  or  the  irrational  use  of  extraneous 
articles  added  to  the  dietary  act  as  causes.  Improper  feeding  habits 
will  bring  on  occasional  attacks.  Sweets,  unripe  fruits,  and  pastries  in 
older  children  or  even  large  quantities  of  one  kind  of  food  may  produce 
an  attack.  Usually  there  is  more  or  less  involvement  of  the  intestinal 
tract. 

Symptomatology. — The  symptoms  very  often  begin  suddenly 
with  fever,  headache,  abdominal  pain,  and  vomiting.  The  temperature 
may  reach  104°  F.  with  a  correspondingly  high  pulse  rate.  The 
vomiting  is  repeated  several  times,  and  the  evidences  of  undigested 
food,  or  a  certain  article  of  food  which  has  caused  the  attack,  as  unripe 
fruit,  are  seen  therein.  The  patient  is  chilly  at  times  and  apt  to  be 
sleepy.  Food  is  abhorent,  the  tongue  is  coated  with  a  thick  fur,  and 
the  breath  is  disagreeable.  Occasionally  convulsions  occur,  especially 
in  neurotic  children.  After  the  vomiting  has  ceased  or  a  (compen- 
satory) diarrhea  has  set  in,  there  is  relief  from  the  distressing  symp- 
toms, although  nausea  and  vomiting  may  reappear  if  the  child  is 
pressed  to  eat. 

Prognosis. — This  is  usually  very  favorable,  although  the  onset  of 
convulsion  in  a  weakly  infant  would  warrant  a  guarded  prognosis. 

Treatment. —  In  breast-fed  infants,  examine  the  mother's  milk, 
and  give  plain  boiled  water  until  vomiting  and  fever  have  subsided; 
a  cleansing  enema  will  complete  the  cure  if  the  milk  is  not  perma- 
nently abnormal.  Bottle-fed  infants  suffer  often  from  this  malady, 
and  the  food  formula  and  its  preparation  should  be  inquired  into 
most  minutely,  for  well-intentioned  attendants  often  make  griev- 
ous errors.  Calomel  gr.  i  in  divided  doses  every  ten  minutes  will 
clear  the  bowels.  If  there  is  a  convulsion,  clean  out  the  bowels  at  once 
with  an  enema  and  later  wash  out  the  stomach  if  vomiting  has  not  been 
free.  In  all  cases  the  patient  should  be  put  to  bed,  without  a  pillow, 
and  a  mustard  paste  applied  to  the  epigastrium  in  the  strength  of  one 
to  seven  of  flour.  The  fever  is  controlled  by  sponging  with  alcohol  and 
water.  Dietetic  management  is  very  important.  Infants  may  be 
kept  on  albumin  water,  cereal  decoctions,  or  whey,  and  then  gradually 
returned  to  their  regular  feedings.  Older  children  are  not  allowed  to 
take  any  food  for  twelve  to  twenty-four  hours,  except  sips  of  cold 
water.  Then  beef  tea,  toast,  and  crackers  are  allowed  and  later  milk, 
milk  toast,  etc.,  slowly  returning  to  the  regular  diet. 


DISEASES  OF  THE  DIGESTIVE  TRACT.  191 

Chronic  Gastritis. 

Definition. — A  chronic  inflammatory  disturbance  of  the  gastric 
function,  associated  usually  with  a  similar  involvement  of  the  intestinal 
tract. 

Etiology. — Improper  feeding  at  irregular  intervals  is  the  main 
cause,  especially  when  coupled  with  bad  hygienic  living.  Rickets, 
tuberculosis,  and  chronic  affections  of  the  liver  predispose  to  a  chronic 
gastritis.  Among  the  well-to-do  or  pampered  children  it  results  from 
the  use  of  sweets,  pastries,  and  rich  dressings  which  the  child  is 
allowed  to  have. 

Symptomatology. — ^Frequent  vomiting  first  attracts  the  attention 
of  the  parent.  This  after  a  time  follows  each  meal.  There  are  eructa- 
tions of  gas  and  a  feeling  of  discomfort  after  eating.  The  tongue  is 
coated.  The  appetite  is  capricious.  The  outline  of  the  stomach 
shows  a  well-marked  dilatation.  The  abdomen  remains  quite  per- 
sistently distended  in  spite  of  medication.  The  child  is  fretful  and 
restless  in  sleep;  the  weight  falling  off  gradually  in  aggravated  cases. 
In  infancy  the  picture  of  marasmus  may  be  seen.  Periods  of  pros- 
tration and  collapse  may  precede  a  lingering  death.  Older  children 
show  no  inclination  to  play,  slowly  grow  more  feeble  and  flabby;  mucus 
is  seen  with  greater  regularity  and  in  greater  quantity  in  the  vomitus. 

Diagnosis. — From  a  basilar  meningitis  the  disease  may  be  dis- 
tinguished by  the  absence  of  stupor  or  coma  and  lack  of  reflex  changes. 
In  doubtful  cases  the  Von  Pirquet  reaction  or  a  study  of  the  spinal 
fluid  could  be  resorted  to  for  verification.  Pyloric  stenosis  should  be 
excluded  by  careful  physical  examination  and  the  character  of  the 
vomiting. 

Course  and  Prognosis. — The  disease  may  last  for  weeks  and  the 
child  drag  on  a  miserable  existence  until  it  succumbs  to  a  terminal  dis- 
ease, such  as  bronchopneumonia  or  marasmus.  Infants  rarely  with- 
stand the  disease,  while  if  they  survive  they  are  apt  to  be  weak  and 
puny.  In  older  children  the  prognosis  is  better  and  treatment  of 
greater  avail,  although  convalescence  is  prolonged  sometimes  through 
months. 

Treatment. — If  all  children  were  brought  at  stated  intervals 
to  their  physician  for  examination  and  counsel,  whether  well  or  ill, 
chronic  gastritis  would  be  a  much  rarer  disease.  "Proper  food  prop- 
erly given"  is  the  prophylactic  treatment.  The  treatment  is  mainly 
dietetic.  A  careful  history  and  study  of  the  previous  diet  is  the  first 
requisite.  Find  the  factor  that  is  causing  the  disturbance;  determine 
whether  it  is  the  butter  fat,  carbohydrates,  or  protein  elements,  for 


192  •    DISEASES  OF  CHILDREN. 

example,  that  is  at  fault.  The  periods  of  feeding,  the  quantity,  the 
quality,  and  the  digestive  ability  of  the  stomach  itself  must  be  weighed 
in  the  balance  and  corrective  measures  instituted  as  described  in  the 
chapter  on  Infant  Feeding.  The  fact  must  not  be  lost  sight  of  that 
some  children  cannot  digest  cow's  milk  in  any  form.  For  the  correc- 
tion of  the  vomiting  and  to  control  the  failing  nutrition  it  is  necessary 
to  supply  such  food  as  will  meet  the  lowest  nutritional  requirements, 
and  in  as  readily  a  digestible  form  as  possible.  It  is  well  to  wash  out 
the  stomach  before  beginning  the  treatment.  The  legume  flours,  as 
pointed  out  by  Edsall  and  Miller,  are  excellent  substitutes  for  cow's 
milk  if  it  disagrees,  and  they  furnish  sufficient  protein  to  keep  up  nutri- 
tion. Beef  blood,  yolk  of  egg,  and  gruels  are  to  be  tried,  and  if  they 
agree,  that  is,  cause  no  vomiting,  may  be  alternated  so  that  they  will 
not  pall  on  the  appetite.  If  an  increase  in  weight  is  obtained,  weak- 
ened regular  milk  feedings  may  then  be  cautiously  tried.  Occasionally 
the  stomach-tube  must  be  used  in  obstinate  cases.  Rectal  feeding  is 
without  much  merit  in  these  cases.  Children  two  to  three  years  old 
are  often  benefited  by  a  change  to  the  seashore.  The  appetite  is 
thereby  stimulated  and  the  strict  dietetic  regime  more  willingly  fol- 
lowed. A  special  diet  list  should  be  prepared  by  the  physician  for 
each  case.  From  this  should  be  excluded  all  sweets,  gravies,  and 
pastries.  Milk,  gruels,  eggs,  and  the  softer  vegetables  should  be  the 
mainstay.  Coupled  with  the  dietetic  management,  the  daily  routine 
of  the  child  should  be  outlined.  A  fresh-air  life,  plenty  of  sleep,  plenty 
of  water  to  drink,  and  agreeable  baths  are  necessities.  Cases  seen 
late  or  doing  badly  require  stimulation,  and  this  is  best  given  in  the 
form  of  the  tincture  of  nux  vomica  one  minim  well  diluted  one-half 
hour  before  meals.  Constipation  is  relieved  by  milk  of  magnesia  or 
cascara  in  children  or  with  a  suppository  in  infants. 

Dilatation  of  the  Stomach. 

Etiology. — This  condition  results  from  causes  which  tend  to 
weaken  the  muscular  walls  of  the  stomach.  It  is  more  commonly  ob- 
served in  infants  suffering  from  constitutional  diseases,  such  as  rickets 
marasmus,  syphilis,  and  tuberculosis.  Among  the  rarer  causes  are 
pyloric  hypertrophy  or  stricture. 

Symptomatology. — Those  which  result  in  the  course  of  the  consti- 
tutional diseases  will  be  here  described.  Vomiting  occurs  usually 
some  time  after  meals;  food  is  not  taken  with  avidity,  and  later  in  the 
disease  may  be  abhorent.  Constipation  is  a  noticeable  symptom. 
The  abdomen  is  usually  tympanitic,  tongue  coated,  and  in  older  chil- 
dren headaches  may  be  complained  of. 


DISEASES  OF  THE  DIGESTIVE  TRACT.  193 

Physical  Examination. — In  emaciated  subjects  the  greater  cur- 
vature of  the  stomach  may  be  seen  on  inspection.  The  abdomen  is 
generally  prominent,  but  percussion  over  the  dilated  viscus  gives  a 
highly  resonant  tympanitic  note.  If  fluid  is  present  a  succussion  note 
can  be  obtained  by  tapping  with  the  ends  of  the  fingers.  If  the  diagno- 
sis is  still  indefinite,  water  or  air  may  be  introduced  as  an  aid  in  deter- 
mining its  size  and  capacity. 

Prognosis. — Unless  due  to  a  congenital  stenosis,  the  prognosis  is 
fairly  good,  but  the  course  is  slow  and  dependent  upon  the  underlying 
disease.  In  itself  the  condition  may  retard  the  progress  of  a  case  of 
rachitis,  for  example,  or  even  become  the  factor  that  may  lead  to  a 
fatal  termination. 

Treatment. — The  motor  inactivity  necessitates  in  the  beginning  a 
course  of  gastric  lavage  coupled  with  dietary  regulations  as  outlined 
under  the  article  on  Chronic  Gastritis.  Fresh  air,  massage,  electricity, 
or  vibration  will  be  additional  aids,  no  matter  what  the  underlying  dis- 
ease. The  tincture  of  nux  vomica  in  small  doses  will  stimulate  the 
appetite  and  assist  the  motor  functions.  If  the  disease  is  depen- 
dent upon  a  stricture,  radical  measures  may  be  necessary  to  effect 
a  cure. 

Stenosis  of  the  Pylorus  and  Pyloric  Spasm. 
(Congenital  hypertrophy  of  the  pylorus.) 

This  is  a  condition  in  infancy  in  which  there  occurs  an  obstruction 
to  the  passage  of  food  from  the  stomach  as  a  result  of  hypertrophy 
or  spasm  of  the  pylorus. 

Etiology. — There  are  no  positive  etiological  factors  known. 

Pathology. — The  muscular,  and  occasionally  the  connective  tissue 
at  the  pylorus,  is  hypertrophied.  The  stomach  is  dilated  and  thick 
tenacious  mucus  is  found  on  the  mucous  membrane. 

Symptomatology. — The  disease  is  usually  not  recognized  when  the 
first  symptom  appears.  An  apparently  healthy  infant  at  the  breast 
may  begin  to  vomit  after  nursing.  This  being  repeated  at  frequent 
intervals,  advice  is  sought.  The  usual  corrective  measures  do  not 
suffice  and  the  vomiting  is  more  persistent.  Closer  observation  will 
show  that  the  stools  are  extremely  small,  that  the  urine  is  scanty,  and 
that  the  vomitus  is  projectile  in  type.  The  diagnosis  now  becomes 
more  apparent.  Physical  examination  may  show  a  thickening  about 
the  pylorus,  especially  if  anesthesia  is  used,  but  this  is  not  always 
present.  The  cases  of  simple  pyloric  spasm  do  not  give  evidences  of 
tumor  formation;  the  vomiting  is  not  quite  so  persistent,  and  th6 
13 


194 


DISEASES  OF  CHILDREN. 


emaciation  not  so  rapid.  The  stools  are  small  and  like  dry  putty, 
sometimes  alternating  with  diarrhea.  Owing  to  the  obstruction, 
little  or  no  chyme  enters  the  duodenum,  and  progressive  emaciation 
results.  The  stomach  is  dilated,  but  the  intestines  are  collapsed, 
q,  valuable  sign  in  this  disease.     A  peristaltic  wave  may  be  observed 


Fig.  58. — (a)  From  a  case  of  congenital  hypertrophic  pyloric  stenosis:  infant 
six  weeks  old — seen  by  one  of  us      (b)  section  of  tumor  in  same  case. 


passing  from  left  to  right  upon  slight  mechanical  stimulation.  Ex- 
amination of  the  stomach  contents  shows  a  mixture  of  food  and 
mucus,  but  without  any  bile.  Hyperchlorhydria  may  be  present. 
If  measures  for  relief  have  not  been  successful  the  child  dies  of 
starvation. 

•Diagnosis. — The  characteristic  vomiting  without  dietetic  error, 
visible  peristalsis,  and   a  palpable  tumor  are  of  especial  diagnostic 


DISEASES  OF  THE  DIGESTIVE  TRACT.  105 

importance.  If  to  these  are  added  the  sunken  abdomen  and  pro- 
gressive emaciation,  the  diagnosis  should  be  more  certain. 

Course  and  Prognosis. — In  cases  of  true  stenosis,  due  to  hyper- 
trophy, the  course  is  progressively  downward  and,  unless  there  is 
successful  intervention,  ends  fatally  in  six  to  ten  weeks.  (Some  cases 
reported  lived  to  twenty  weeks  and  one  five  years.)  Cases  have  been 
cured  by  medical  treatment  alone,  but  appear  to  be  those  in  which 
there  was  spasm  only  present  and  not  a  true  stenosis.  Heubner  is 
inclined  to  give  a  hopeful  prognosis  with  palliative  treatment.  It  is 
certain  that  the  older  the  infant  becomes  before  symptoms  appear, 
the  better  its  chances  for  recovery. 

Treatment. — As  soon  as  the  diagnosis  is  made,  stomach  washing 
should  be  regularly  done  twice  a  day.  The  food,  preferably 
breast  milk,  should  be  fed  by  gavage  and  always  after  the  stomach 
washing. 

Mustard  applications,  one  to  six  of  flour,  may  be  tried  before 
feedings.  If  the  vomiting  persists  so  that  no  gain  is  made,  surgical 
intervention  should  be  resorted  to  as  offering  a  hope  of  recovery. 
The  surgeon  will  elect  to  do  a  gastroenterostomy  or  a  pylorodiosis 
(Loreta's  operation).  As  the  number  of  failures  reported  is  far 
behind  the  cures  recorded,  we  will  offer  no  statistics  on  this  point. 

Cyclic  Vomiting. 

(Recurrent  Vomiting,  Periodic  Vomiting.) 

This  symptom-complex  occurs  in  older  children  and  is  character- 
ized by  periodical  attacks  of  vomiting  and  prostration,  usually  with- 
out fever  and  without  indiscretions  in  diet. 

Etiology. — The  condition  is  usually  ascribed  to  some  form  of 
toxemia.  Children  from  five  to  twelve  years  of  age  are  more  fre- 
quently affected.  It  is  riiore  apt  to  occur  in  the  families  of  the  well- 
to-do  than  in  the  poor.  Metabolism  is  disturbed,  as  shown  by  the 
presence  of  the  acetone  and  diacetic  acids  in  the  urine.  Edsall 
believes  that  in  the  majority  of  cases  faulty  digestion  is  the  underlying 
factor. 

Symptomatology. — In  cases  already  under  observation,  a  prodro- 
mal stage  may  sometimes  be  detected,  but  for  the  most  part  the  attack 
comes  on  suddenly  in  children  who  are  considered  to  be  in  good  health. 
Occasionally  constipation,  lassitude,  loss  of  appetite  and  a  slight 
temperature  precede  the  attack.  The  vomiting  is  persistent,  recurs 
frequently  and  sometimes  contains  blood;  nothing  is  retained.  The 
child  soon  shows  the  effects  of  the  strain,  lying  quite  prostrated  with 


196  DISEASES  OF  CHILDREN. 

sunken  eyes,  anxious  expression,  coated  tongue,  sweetish  breath,  and 
a  high  pulse.  Thirst  is  a  prominent  symptom  and  cannot  be  reHeved 
on  account  of  the  vomiting.  The  abdomen  becomes  scaphoid  in 
shape,  and  sometimes  is  sensitive  to  the  touch.  Constipation  is  almost 
the  rule.  There  may  be  periods  in  which  vomiting  ceases  for  a  short 
time  and  some  fluid  or  food  can  be  retained.  The  attacks  recur  in 
varying  periods — it  may  be  weeks  or  months.  The  urine  when 
examined  is  found  deficient  in  amount  and  clouded,  and  usually  gives  a 
marked  acetone  reaction,  Indican,  diacetic  acid,  albumin,  and  casts  are 
occasionally  found.  Recovery  is  rapid  when  the  attack  has  ceased 
and  food  can  be  retained. 

Diagnosis. — This  must  be  made  after  excluding  meningitis,, 
nephritis,  and  appendicitis.  The  sudden  onset,  acetone  breath, 
absence  of  high  temperature  in  a  child  without  a  history  of  dietary 
indiscretion,  would  call  attention  to  this  symptom-complex. 

Prognosis. — As  to  life,  the  prognosis  is  distinctly  favorable,  although 
fatal  cases  have  been  reported.  The  attacks  tend  to  recur  unless  the 
underlying  cause  be  removed. 

Treatment. — Of  the  attack.  Rest  of  body  and  stomach  are 
essential;  nothing  should  be  given  by  mouth.  To  allay  the  thirst, 
colonic  irrigations  of  normal  salt  solution,  allowing  four  to  six 
ounces  to  be  retained,  are  effective.  If  the  attacks  persist  beyond 
the  second  or  third  day,  codein  hypodermatically  may  be  neces- 
sary, followed  by  nutrient  enemata.  Peptonized  milk  with  whisky 
serves  this  purpose.  Small  doses  of  carbonated  water  may  be  tried 
when  the  vomiting  begins  to  abate.  Later,  hot  broths,  dextrinized 
gruels,  orange  juice  and  semisolid  food  is  offered  until  convalescence 
is  established. 

In  the  Interval. — This  should  be  influenced  by  the  family  history, 
the  dietetic  faults,  and  an  examination  of  the  urine.  The  child  should 
be  under  constant  medical  supervision.  A  suitable  diet  list  should 
be  prepared,  and  its  effect  on  the  urine  noticed.  The  bowels  should 
never  be  allowed  to  be  constipated.  A  specific  amount  of  water  should 
be  given  daily.  The  daily  life  of  the  child  must  be  apportioned,  as  in 
this  way  only  may  we  hope  to  prevent  recurrences. 

Stools. 

The  stools  of  the  breast-fed  infant  may  be  from  one  to -five  in 
number,  and  numerically  we  should  not  judge  them  as  abnormal,  pro- 
vided their  color,  consistency,  and  odor  are  within  the  normal  limits. 
Their  color  should  be  a  yellow  or  orange  tint  with  homogeneous  con- 


DISEASES  OF  THE  DIGESTIVE  TRACT.  197 

sistency  produced  by  the  unchanged  bilirubin.  Their  reaction  should 
be  acid  and  the  odor  not  disagreeable.  The  amount  of  residue  found 
in  the  stools  will  be  in  direct  proportion  to  the  amount  ingested  or 
retained.  The  latter  statement,  however,  does  not  hold  true  for  the 
babies  artificially  fed. 

Stools  of  Artificially  Fed  Infants. — Cow's  milk  normally  produces 
a  stool  lighter  in  color,  bulkier,  and  numerically  fewer.  The  feces 
amount  to  about  5  per  cent,  of  the  food  ingested.  In  the  hand-fed 
infant  the  protein  elements  are  longer  exposed  in  the  intestinal  canal 
to  putrefaction. 

Examination  of  Stools. — If  we  examine  a  freshly  passed  stool  from 
an  infant  fed  on  human  milk,  and  with  an  improvised  spatula  spread 
out  a  central  portion,  we  may  find  that  there  are  yellow  masses  or 
flakes  present;  these  are  often  mistaken  for  curds,  but  in  reality  are 
made  up  of  fats;  firm,  hard  curds  are  not  found  in  mother's  milk — only 
in  cow's  milk.  Such  a  stool  in  an  infant  not  steadily  gaining  would  in- 
dicate a  scanty  milk  supply,  and  if  the  stools  were  frequent,  dark 
green  and  mucoid,  with  very  little  milk  residue,  the  maternal  font 
would  surely  be  found  to  be  at  a  low  ebb.  The  indication  would  be 
wet-nursing  or  alternate  feedings  and  regulation  of  the  diet  and  life 
of  the  nurse. 

In  the  bottle-fed  baby  we  are  often  confronted  with  the  symptoms 
of  constipation  or  diarrhea.  Either  of  these  conditions  may  arise 
from  too  much  protein  in  the  food.  The  constipated  stool  will 
be  friable,  like  dry  putty,  while  the  loose  stool  due  to  this  cause 
can  be  smoothed  out  and  the  masses  will  be  readily  soluble  in 
ether,  proving  them  to  be  fat  and  not  curds,  as  they  are  so  often 
designated. 

True  curds  are  formed  in  the  stomach  by  the  action  of  lactic  acid 
or  an  excess  of  hydrochloric  acid  and  rennet  on  the  paracasein.  They 
are  hard,  smooth,  yellowish  on  the  outside  and  white  within,  with  a 
cheesy  odor  when  opened,  and  will  not  dissolve  in  ether.  The  remedy 
for  too  much  protein  is  evident.  Correct  the  formula,  and  if  true  curds 
are  present,  examine  the  character  of  the  milk.  The  milk  may  have 
been  sterilized  or  it  needs  to  be  mechanically  diluted  with  gruels,  or 
chemically  modified,  when  the  stools  will  assume  the  normal  type.  A 
loose,  greasy,  sour-smelling,  acid  movement,  resembling  scrambled 
eggs,  will  indicate  excessive  fat  in  the  dietary.  Examination  of  the 
breast  milk  or  a  study  of  the  formula  will  show  that  the  fats  ingested 
have  been  persistenth'  too  high.  Three  per  cent,  of  fat  should  never  be 
exceeded  by  an  infant  to  the  third  or  fourth  month,  and  more  than 
four  per  cent,  should  never  be  prescribed.     It  should  be  recollected 


198  DISEASES  OF  CHILDREN. 

that  a  certain  amount  of  fat  is  always  present,  but  should  not  be  visible 
in  distinct  masses. 

Mothers  often  erroneously  speak  of  large  quantities  of  mucus  as 
present  in  the  baby's  stools.  The  doctor  must  remember  that  some 
mucus  is  normal;  that  it  should,  however,  be  found  intimately  mixed 
with  the  feces.  Barley  water  produces  a  slimy  stool  often  mistaken 
for  mucus,  and  undigested  food  elements  also  cause  this  error.  If 
mucus  is  seen  in  any  quantity  with  the  naked  eye  by  a  competent  ob- 
server, it  is  pathological  and  means  inflammation,  usually  located  in 
the  large  intestine,  of  a  subacute  or  chronic  form.  If  the  disease  is  in 
the  small  intestine,  the  mucus  is  mixed  with  the  stool  and  it  is  usually 
found  to  be  bile-stained.  The  hint  for  correction  is  embodied  in  the 
following  fact — that  the  greater  the  amount  of  nonassimilable 
substances  present,  the  greater  the  amount  of  mucus.  The  color  of 
the  stools  when  immediately  passed  should  be  considered.  If  the 
absorptive  process  has  been  delayed  and  putrefactive  changes  have 
taken  place  in  the  protein  element,  the  bilirubin  will  be  changed  to 
biliverdin,  but  it  is  not  known  whether  the  reaction  itself,  or  chromo- 
genic  bacteria,  produce  the  coloration.  Nitric  acid  will  prove  whether 
or  not  we  are  dealing  with  bile  salts  by  the  familiar  play  of  colors. 
The  green  color  in  conjunction  with  mucus,  and  fecal  acid  reaction, 
indicate  true  intestinal  disease  and  call  for  radical  change  in  the  die- 
tary. Acid  fermentation  will  require  such  temporary  food  as  albumin 
water  for  its  correction,  while  alkaline  putrefaction  will  respond  to  the 
carbohydrate  foods,  as  dextrinized  gruels.  The  brownish  movements 
often  seen,  if  we  exclude  certain  drugs  and  blood,  are  due  to  the  inges- 
tion of  undextrinized  starches  alone,  or  a  preponderance  of  carbohy- 
drates in  proprietary  infant  foods. 

A  stool  that  presents  a  foamy,  bubbling  appearance  and  is  acid 
in  reaction  will  signify  the  presence  of  too  much  sugar  in  the  mixture, 
as  is  often  the  case  in  canned  condensed-milk  feedings. 

We  have  not  hinted  at  the  bacterial  examination  of  the  stools,  as 
it  has  proven  of  no  clinical  value  as  yet.  The  reaction  of  the  stool  is  a 
help  and  should  be  ascertained,  and  always  taken  from  the  middle  of 
the  fresh  stool.  If  a  blue  color  is  obtained,  we  have  alkaline  protein 
putrefaction  going  on,  and  if  the  color  of  the  litmus  is  unchanged,  we 
have  acid  fermentation  due  to  the  breaking  down  of  the  fats  and 
carbohydrates. 

Again,  the  stools  may  be  of  considerable  aid  to  us  in  certain 
pathological  conditions,  as  illustrations  of  the  intensity  of  the  process 
in  the  summer  diarrheas,  and  in  such  pathological  states  as  intus- 
susception, in  which  we  have  frequent  paroxysmal  discharges  with 


DISEASES  OF  THE  DIGESTIVE  TRACT.  199 

blood  and  mucus,  but  no  feces.  Rectal  polypi  should  be  strongly 
suspected  where  we  have  a  normal  stool,  except  for  a  fresh-blood 
coating;  these  hemorrhages  being  intermittent  in  character  and  not 
necessarily  connected  with  a  hard  or  scybalous  mass.  Fissures  may 
be  produced  by  hard  fecal  masses  and  have  a  blood  coating,  or  in 
their  passage  produce  bleeding  from  the  rectum.  Dark  grumous  blood 
mixed  with  the  feces  is  indicative  of  hemorrhage,  higher  up  in  the 
bowel — probably  from  intestinal  ulcerations.  In  gastric  or  acute 
duodenal  ulcer  there  is  vomiting  of  blood  and  mucus,  but  there  is  no 
fresh  blood  in  the  stools. 


Colic. 

(Enteralgia.) 

The  term  colic  is  used  to  designate  the  paroxysmal  pains  which 
occur  in  the  abdomen.  It  is  a  symptom  and  not  a  disease,  and  usually 
denotes  the  presence  of  an  abnormal  amount  of  gas  in  the  intestines, 
which  stimulates  undue  peristaltic  movements. 

Etiology. — It  occurs  most  frequently  in  artificially  fed,  babies,  as 
a  result  of  digestive  disturbances  dependent  upon  the  food  ingested. 
This  food  may  have  been  unwholesome,  too  great  in  amount,  or  one 
of  its  constituents  may  have  been  in  excess.  For  example,  the  per- 
centage of  proteins  in  a  given  mixture  may  be  too  high,  or  the  sugar 
may  cause  fermentation  if  present  in  undue  amounts  (beyond  6  per 
cent.),  or  there  may  be  starchy  indigestion.  Breast-fed  infants  may 
suffer  from  a  poorly  balanced  milk  or  from  overfeeding  or  too  hasty 
nursing. 

Colic  occurring  in  the  course  of  other  disease  is  dependent  upon 
the  resulting  atonic  condition  of  the  intestinal  walls. 

Symptomatology. — The  attacks  come  on  suddenly,  the  infant  is 
restless  and  uneasy,  and  cries  unceasingly.  The  abdomen  is  dis- 
tended and  rigid  and  the  thighs  are  drawn  up  over  the  abdomen. 
The  extremities  may  be  cold.  If  during  the  examination  some  flatus 
is  expelled  the  screaming  ceases  and  the  evidences  of  relief  are 
apparent. 

Treatment. — In  the  attack,  heat  should  be  applied  to  the 
abdomen,  an  enema  of  warm  saline  solution  should  be  given  and  sips 
of  hot  water  given  by  mouth.  These  measures  will  usually  be  effec- 
tive. If  relief  is  not  obtained,  massage  of  the  abdomen  with  warm 
olive  oil,  followed  by  a  hot  colonic  irrigation  containing  two  drams 
of  the  milk  of  asafetida  to  four  ounces  of  water  can  be  used. 


200  ■     DISEASES  OF  CHILDREN, 

The  following  prescription  may  be  of  occasional  service: 

I^.     Chlorali  hydrati gr.  viii 

Sodii  bicarbonatis gr.  x 

Sodii  bromidi 3ss 

Aquae  menthse  pipertse 3ss 

Aquae q.  s.  ad   5ij 

Misce  et  signa. — Give  a  teaspoonful  in  a  little  hot  water  every 
two  or  three  hours. 

The  further  treatment  resolves  itself  into  efforts  to  discover  the 
cause  of  the  colic.  The  details  of  the  preparation  and  administration 
of  the  infant's  food  may  disclose  a  fault  worthy  of  correction.  The 
care  of  the  mother  or  wet-nurse  must  not  be  forgotten  when  colic 
is  present  in  the  breast  fed. 

Acute  Gastroenteritis. 
{Summer  Diarrhea.     Summer  Complaint.    Infectious  Diarrhea.) 

Etiology. — Artificially  fed  babies  in  the  hot,  humid  summer 
months  are  especially  prone  to  this  infection,  superinduced  by  the 
ingestion  of  unwholesome  milk.  Infants  and  children  under  two 
years  are  mainly  attacked.  The  children  in  the  tenement-house 
districts  of  our  large  cities  show  the  greatest  morbidity  to  infectious 
diarrhea.  The  bacillus  dysenteriae  (Shiga-Flexner  bacillus)  can  be 
isolated  from  many  of  the  stools.  The  infection  is  usually  from  with- 
out, but  autoinfection  is  possible.  The  lack  of  refrigeration,  the 
feeding  of  food  unfitted  to  the  age,  plus  the  devitalization  by  the 
summer  heat,  makes  infection  easy  and  common.  Babies  in  crowded 
hospital  wards  may  become  infected  by  careless  handling  of  the 
soiled  diapers. 

Pathology. — No  special  characteristics  are  observed  at  necropsy. 
A  congested  mucous  membrane  in  the  stomach  and  small  intestine, 
with  enlarged  lymph  glands,  are  commonly  observed.  Cloudy  swelling 
of  the  kidneys  is  quite  constant. 

Symptomatology. — Mild  Form. — The  stools  first  attract  attention. 
The}'  are  curdy,  loose  and  foul.  The  fever  is  moderate  and  the  child 
fretful.  The  character  of  the  stools  soon  changes  to  a  greenish-yellow, 
and  they  become  more  numerous,  five  to  six  a  day,  and  the  fever 
rises  to  102^  or  103°  F.  If  prompt  measures,  as  indicated  below,  are 
taken,  recovery  is  rapid  and  quite  certain. 

Severe  Form. —  Vomiting  with  loose,  frequent  spinach-green 
stools  and  high  fever  may  be  seen  at  the  outset  or  result  from  neglect 
of  the  milder  types.  Vomiting  follows  the  ingestion  of  nearly  all  the 
food  offered.  The  fever  and  inability  to  take  food  j)roduce  weakness 
and  extremely  rapid  emaciation,  and  later  a  comatose  condition  with 


DISEASES  OF  THE  DIGESTIVE  TRACT.  201 

marked  prostration.  The  fontanel  is  sunken  and  the  pulse  is  weak. 
The  stools  may  be  streaked  with  blood  and  contain  mucus  in  consider- 
able quantity.  The  fever  frequently  rises  to  104°  or  105°,  F.  and 
death  may  be  preceded  by  coma  or  convulsions. 

Toxic  Form. — From  the  onset  the  symptoms  are  usually  severe. 
High  fever  and  intense  prostration  are  added  to  the  vomiting  and 
frequent  stools.  The  color  of  the  stools  is  constantly  green,  the  odor 
extremely  foul,  and  blood-streaked  mucus  appears  early.  Cerebral 
symptoms  soon  supervene,  delirium  and  coma  usher  in  the  end,  which 
may  come  on  in  a  day  or  two,  or  even  within  twenty-four  hours.  In 
this  form  the  Shiga  bacillus  can  usually  be  demonstrated. 

Course  and  Prognosis. — This  has  been  indicated  under  the 
separate  divisions,  depending  upon  the  severity  of  the  infection.  If 
seen  early,  the  mild  and  severer  forms  are  amenable  to  treatment, 
while  the  toxic  type  usually  baffles  even  the  most  heroic  measures. 
The  ability  to  command  good  nursing  and  change  of  locality  naturally 
influence  the  prognosis. 

Treatment.  Prophylactic.  —  Breast-feeding  whenever  possible, 
especially  in  the  summer  months,  is  desirable.  Cleanliness  and  care 
in  every  detail  of  the  child's  diet  and  clothing  are  necessary.  The 
use  of  pasteurized  or  constantly  refrigerated  clean  milk  is  indicated. 
Proper  disinfection  of  stools  and  the  nurse's  hands  must  be  insisted  on. 
Regulation  of  the  diet,  according  to  the  heat  and  the  condition  of  the 
infant,  will  help  in  prevention. 

General  Management. — Place  the  patient  in  the  coolest,  cleanest 
and  largest  room  possible.  A  cotton  slip  and  diapers  only  are  to  be  worn. 
Secure  a  competent  nurse  if  possible  to  intelligently  follow  orders.  Re- 
duce the  fever  by  frequent  cool  sponging  or  tepid  baths.  If  the  tempera- 
ture is  above  104°  F.  and  the  pulse  permits,  use  an  ice-bag  to  the  head. 
An  initial  purge  with  castor  oil  or  calomel  is  indicated  (see  p.  203). 

Dietetic. — Stop  milk  in  all  forms  for  at  least  twenty-four  hours, 
placing  the  child  on  a  starvation  diet  of  boiled  water  alone  or  on  barley 
water,  made  with  one  ounce  of  fiour  to  the  quart.  If  at  the  end  of  a 
day  the  frequent  stools  persist,  continue  the  substitute  feeding  until 
a  change  for  the  better  is  noticed. 

If  barley  gruel  is  not  palatable  or  tolerated,  one  may  try  rice  water 
or  albumin  water.  (See  section  on  Dietetics.)  In  the  case  of  nurslings 
resume  the  feeding  at  longer  intervals  preceded  by  a  dram  or  two  of 
boiled  water.  In  artificially  fed  babies,  resumption  to  cow's  milk 
feedings  must  be  made  only  when  the  stools  resume  the  normal  type. 
Whey  or  buttermilk  feedings  are  serviceable  substitutes.  Begin  with 
a  modification  lower  than  the  original  prescriptions. 


202  DISEASES  OF  CHILDREN. 

The  diarrheal  diseases  of  infancy  and  childhood  do  not  permit  as 
yet  of  any  definite  classification,  for  the  etiological  factors  may  be 
the  same  in  a  number  of  the  allied  affections,  and  the  various  patho- 
logical changes  found  are  often  those  of  degree  or  situation  only.  It  is 
to  be  hoped  that  in  the  near  future  these  grouped  diseases  may  be 
more  accurately  separated  and  defined. 

Acute  Enterocolitis. 

Definition. — This  is  an  inflammation  of  the  mucous  membrane  of 
the  small  and  large  intestine  associated  with  ulcerations  and  charac- 
terized by  tenesmus  and  blood-stained  stools. 

Etiology. — Children  in  the  summer  months,  especially  those  who 
have  had  previous  attacks  of  gastroenteritis,  or  who  suffer  from 
chronic  indigestion,  are  especially  liable  to  attack.  The  children  of  the 
poor  in  the  large  cities  because  of  improper  food  and  uncleanliness  are 
most  frequently  the  victims  of  the  disease.  Such  constitutional  dis- 
eases as  rickets,  tuberculosis,  and  syphilis  are  predisposing  elements. 
The  Shiga  bacillus  is  found  in  a  great  many  of  the  cases. 

Pathology. — In  the  colon  and  about  the  ileocecal  valve  the  charac- 
teristic lesions  are  commonly  observed.  In  some  of  the  lighter  forms 
of  the  disease  we  find  only  evidences  of  congestion  and  inflammation 
with  a  roughened  or  somewhat  denuded  epithelium. 

The  lymphatic  structures  are  hypertrophied  or  show  loss  of  tissue. 
If  the  affection  has  been  of  a  severer  grade,  the  follicles  are  degenerated, 
producing  a  slight  ulceration  and  consequent  uneven  feel  to  the  gut. 
These  changes  are  commonly  seen  in  the  colon  and  rarely  in  the 
ileum  or  rectum.  In  the  usual  type  seen  after  a  severe  illness  quite 
deep  ulceration  may  exist,  so  as  to  produce  a  shaven  beard  appearance. 
The  ulcers  may  later  extend  down  to  the  muscular  layer,  and  a  large 
area  of  ulceration  may  be  found  by  the  coalition  of  a  number  of  smaller 
ulcers.  Another  type  occasionally  seen  presents  a  fibrinous  deposit 
over  isolated  areas  of  the  colon.  Quite  generally  there  is  a  swelling 
of  the  retroperitoneal  and  mesenteric  glands.  Bronchopneumonic 
patches  are  often  found  at  necropsy. 

Symptomatology. — In  a  child  whose  vitality  has  already  been  im- 
paired by  previous  disease  the  attention  may  be  directed  to  the  con- 
dition of  the  stools,  which  are  passed  with  much  straining.  Thesp:  stools 
may  contain  blood-streaked  mucus  with  undigested  food  masses. 
Fever  is  quite  constant  and  varied  in  degree,  in  the  beginning  102°  to 
105°  F.  and  a  correspondingly  rapid  pulse  rate.  In  the  severer  cases 
there  is  rapid  prostration  and  vomiting.     The  stools  are  passed  with 


DISEASES  OF  THE  DIGESTIVE  TRACT.  203, 

abdominal  pain,  and  tenesmus  may  be  marked.  There  is  restlessness 
and  often  delirium.  Thirst  is  intense.  The  eyes  are  sunken  and 
expressionless.  The  lips  and  tongue  are  dry  and  coated.  The  stools 
are  now  frequent — from  ten  to  twenty  a  day — small,  and  contain 
almost  no  feces.  Death  will  occur  from  exhaustion  or  a  pneumonic 
complication  if  the  symptoms  do  not  show  signs  of  abatement.  Im- 
provement is  shown  by  a  decrease  in  the  number  of  stools,  a  lowered 
temperature  with  absence  of  vomiting  and  tenesmus.  The  lost  vitality 
is  regained  very  slowly.  For  days  or  weeks  there  is  a  low-grade  tem- 
perature, and  temporarily  the  tenesmus  or  green  stools  may  appear. 

The  appetite  is  capricious  for  a  long  time.  The  abdominal  tone 
which  is  lost  during  the  height  of  the  disease  will  now  slowly  return  to 
the  normal,  and  the  child  will  gain  in  weight. 

Diagnosis. — The  diagnosis  is  made  from  the  presence  of  mucus  and 
blood  in  diarrheal  stools  passed  with  straining  over  a  period  of  several 
days  or  weeks  in  a  child  of  deficient  vitality. 

Intussusception  is  differentiated  by  the  absence  of  fever,  the 
acute  onset,  the  pain,  the  presence  only  of  mucus  and  blood,  but  no 
feces,  and  a  tumor  palpable  through  the  abdomen  or  rectum. 

Course  and  Prognosis. — Severe  types  end  fatally  after  a  few  days, 
or  a  week  at  most,  of  high  fever  and  prostration.  The  mortality  rate 
is  from  30  to  40  per  cent.  The  subacute  types  remain  ill  for  a  month 
or  six  weeks  with  periods  of  remission  and  relapses  and  a  slow  painful 
convalescence.  The  prognosis  is  more  favorable  in  this  class,  especi- 
ally if  they  are  removed  to  suitable  surroundings,  and  hav&  proper  nurs- 
ing and  attendance.     Infants  withstand  the  disease  badly. 

Treatment. — This  does  not  differ  from  that  given  on  page  201, 
under  Diarrheal  Diseases.  It  should  be  recalled  that  these  infections 
may  be  communicated  to  others  in  a  family  or  ward.  An  initial 
cleansing  of  the  bowel  with  castor  oil  or  calomel  is  imperative,  followed 
by  starvation  for  twelve  to  twenty-four  hours.  Egg  albumin,  bar- 
ley water,  or  beef  broth  may  be  given  (see  p.  156).  Equal  parts  of 
beef  broth  or  barley  gruel  (1  oz.  to  the  pint)  are  sometimes  more 
acceptable. 

The  tenesmus  is  relieved  by  the  control  of  the  diet  and  by  the  use 
of  codein  gr.  i  to  |,  according  to  the  age,  or  Dover's  powder,  gr.  ^  to  2 
grains  every  two  or  three  hours,  until  the  painful  symptoms  abate. 
Suppositories  containing  cocain  gr.  \  and  aristol  gr.  i  are  soothing  in 
older  children.  Bismuth  subnitrate  gr.  5-10  or  bismuth  subgallate  gr. 
2,  with  powdered  ipecac  gr.  1,  ma}^  be  given  advantageously  every 
two  or  three  hours  for  the  control  of  the  mucus  and  blood  in  the  stools. 

Whey  is  permitted  when  the  stools  show  improvement,  and  after 


204  DISEASES  OF  CHILDREN. 

the  acute  symptoms  have  subsided  sterilized  milk  is  allowed  in  small 
amounts  well  diluted  with  barley  or  wheat-flour  gruel.  Later  pasteur- 
ized milk  is  permitted  with  jellied  gruels  and  broths.  The  prostration 
may  require  hypodermatic  medication  in  the  form  of  atropin  gr.  ^^^ 
with  strychnin  sulph.  gr.  aiu-  As  a  daily  routine,  one  saline  irrigation 
at  100°  F.  serves  a  double  purpose,  as  a  cleansing  solution  and  for 
absorption  of  part  of  the  water.  Strychnin  sulphate  gr.  ^^^  may  be 
given  as  a  tonic  three  times  a  day,  and  astringent  enemas  for  the 
control  of  blood  and  mucus.  Silver  nitrate  (tttVtt)  o^  ^  starch  paste 
in  less  severe  cases  may  serve  the  latter  purpose.  They  should  not 
be  given  more  than  once  daily,  and  discontinued  if  the  effect  is  not 
satisfactory.  Too  frequent  irrigations  often  cause  irritation  and  ag- 
gravation of  the  symptoms.  Removal  to  the  seaside  or  cool  mountain 
air  is  a  great  help  in  the  management,  particularly  in  the  convalescent 


Chronic  Gastrointestinal  Indigestion. 

This  is  a  condition  congenital  or  acquired,  resulting  from  deficient 
motor  and  secretory  powers  in  the  alimentary  tract,  or  as  a  result 
of  improper  food. 

Etiology. — Improper  feeding,  especially  in  poor  children  in  the 
cities  where  the  surroundings  are  unhygienic,  is  the  principal  cause  of 
this  affection.  When  the  food  is  radically  wrong,  or  unwholesome,  an 
acute  condition  develops  which  makes  the  parent  seek  medical  treat- 
ment; on  the  other  hand,  the  chronic  condition  due  to  incapacity  to 
digest  certain  ingredients  of  the  food  is  often  overlooked  or  ascribed 
to  anemia,  parasites,  etc.  An  excess  of  the  fats,  carbohydrates,  and 
sugars  or  of  the  proteins  may  overtax  the  intestinal  digestion,  thereby 
using  up  energy  which  should  have  produced  development  and  growth. 

In  older  children  badly  prepared  foods  or  indulgence  in  rich  foods, 
pastries,  and  condiments  lead  to  this  condition. 

Pathology. — 'There  are  no  definite  organic  changes  found  in  this 
disease.  If  of  long  standing,  the  lymph  follicles  in  the  region  of  the 
ileocecal  valve  may  be  hypertrophied  or  a  chronic  colitis  may  be 
found. 

Symptomatology. — ^As  indicated  above,  the  symptoms  are  not 
appreciable  at  first,  unless  the  disease  directly  follows  an  acute  gas- 
tritis or  enterocolitis.  After  some  time  failure  to  gain  weight  is 
noticed;  the  child  sleeps  badly,  has  frequent  attacks  of  colic,  and  cannot 
easily  be  comforted;  the  stools  become  diarrheal  for  several  days  then 
resume  a  more  normal  appearance,  only  to  relapse  into  a  condition  of 


DISEASES  OF  THE  DIGESTIVE  TRACT.  205 

diarrhea  or  even  constipation.  Closer  examination  of  the  stools 
shows  that  they  consist  of  masses  of  undigested  food,  intermingled 
with  a  small  quantity  of  mucus,  while  streaks  or  splashes  of  green  color 
are  not  infrequent. 

The  musculature  becomes  soft  and  flabby.  If  the  child  has  pre- 
viously sat  up  or  walked,  it  may  now  be  unable  to  do  so.  The  abdom- 
inal wall  offers  little  or  no  resistance  on  palpation  and  the  normal 
peristalsis  is  sluggish.  The  temperature  is  rarely  elevated  except  late 
in  the  disease;  on  the  other  hand,  a  subnormal  temperature  is  not 
uncommon.  Intertrigo  in  the  napkin  region  is  exceedingly  common. 
If  corrective  measures  have  not  been  instituted  by  this  time  a  marantic 
condition  supervenes  which  may  lead  to  a  fatal  issue. 

In  older  children  the  symptoms  are  not  as  marked,  but  the  sta- 
tionary weight  or  loss  of  weight,  anemia,  and  listlessness  should  recall 
the  possibility  of  this  condition.  The  appetite  is  capricious,  and  as  a 
consequence  the  children  are  indulged  to  a  vicious  degree  by  their 
parents.  Attacks  of  constipation  alternate  with  diarrhea,  the  urine 
is  somewhat  decreased  in  amount,  it  may  be  cloudy,  and  contains 
an  excess  of  indican  (see  Plate  I).  The  children  become  irritable 
and  moody,  having  seemingly  lost  their  former  characteristics.  They 
become  cold  easily,  develop  headaches,  and  are  easily  nauseated. 
The  abdomen  becomes  prominent  from  gas  distention,  the  stomach 
itself,  if  mapped  out,  shows  enlargement,  but  there  is  no  pain  or 
tenderness  on  abdominal  palpation. 

Treatment. — Good  hygiene  and  proper  dietetic  treatment  are 
absolutely  necessary  to  effect  a  cure.  In  the  case  of  the  poor,  removal 
to  a  properly  conducted  hospital,  preferably,  one  near  the  seashore, 
will  often  work  wonders. 

The  diet  must  be  so  adapted  that  it  will  correct  the  former  faults, 
but  still  take  into  consideration  the  deficiency  of  digestive  secretion 
and  maldevelopment  of  the  alimentary  tract.  An  analysis  of  the 
breast  milk  or  of  the  last  formula  given  to  an  infant,  studied  in  con- 
nection with  its  stools,  will  usually  show  which  ingredient  is  at  fault. 
A  wet  nurse  will  sometimes  quickly  produce  an  amelioration  of  the 
symptoms.  Detailed  instructions  as  to  the  room,  air,  bathing,  and 
exercise  must  be  given  if  the  patient  is  to  remain  at  home.  The  roof 
or  piazza  can  be  effectively  utilized,  and  the  greater  part  of  the  day 
should  be  spent  out  of  doors.  Before  any  dietary  changes  are  made 
it  is  well  to  wash  out  the  stomach,  and  thoroughly  irrigate  the  bowels 
with  saline  solution.  In  some  instances  the  bowel  irrigations  may 
have  to  be  repeated  once  or  twice.  An  initial  dose  of  castor  oil,  one 
to  two  drams  and  a   minim  or  two  of  the  tincture  of  nux  vomica, 


206  DISEASES  OF  CHILDREN. 

three  times  a  day,  will  usually  constitute  all  the  drug  treatment  that  is 
necessary. 

If  the  infant  is  artificially  fed,  the  milk  can  for  a  time  be  so 
modified  as  to  prevent  the  curdling  action  of  rennet  in  the  stomach 
by  the  use  of  peptonization  or  the  alkalies  or  the  addition  of  sodium 
citrate.  A  formula  weaker  than  the  requirements  of  a  normal  child  of 
a  corresponding  age  must  be  temporarily  given.  Rapid  gain  in  weight 
must  not  be  expected.     Convalescence  is  slow  and  protracted. 

The  management  in  the  case  of  older  children  is  mainly  dietetic. 
From  time  to  time  a  diet  list  of  certain  permissible  articles  of  food 
should  be  given  beginning  with  such  as  are  easily  digested  and  assimi- 
lated and  gradually  increasing  the  number  and  variety  as  the  improve- 
ment warrants  (see  diet  list,  p.  176). 

Aerotherapy,  stimulating  baths,  and  massage  are  necessary 
adjuncts  to  the  dietetic  treatment.  Without  constant  supervision 
and  attention  to  the  daily  routine,  meager  improvement  will  be 
experienced. 

Congenital  Dilatation  of  the  Colon. 

(Hirschsprung's  Disease.) 

This  is  a  rare  condition  which  consists  of  an  increase  in  the  length 
and  circumference  of  the  descending  colon  and  the  sigmoid  flexure. 
In  some  cases  there  is  an  added  hypertrophy  of  the  muscle  fibers.  As 
a  result  of  this  condition  the  abdomen  is  greatly  distended  from 
meteorism,  feces  are  more  or  less  retained,  the  constipation  is  ex- 
tremely obstinate,  and  when  the  fecal  masses  are  passed,  either  natur- 
ally or  by  artificial  means,  they  are  extremely  foul,  putrescent,  and 
may  be  covered  w^ith  mucus  and  some  blood. 

Treatment. — Daily  high  irrigations  must  be  used  to  produce 
bowel  evacuation.  Massage  and  douching  of  the  abdomen  with  cold 
water  should  be  persisted  in  for  a  long  time.  Internally  the  daily 
administration  of  a  laxative  and  drop  doses  of  the  tincture  of  nux 
vomica  before  meals  are  advisable. 

Cholera  Infantum. 

Cholera  infantum  is  a  very  acute  disease  characterized  by  rapid 
prostration,  vomiting,  and  a  profuse  serous  diarrhea. 

Etiology. — It  occurs  almost  entirely  in  the  hot  months  of  the  year, 
among  the  poorer  classes  who  live  on  inferior  milk,  and  very  rarely 
attacks  breast-fed  infants.  It  is  the  result  of  a  toxic  poisoning  from 
an  organism  or  group  of  organisms  still  undetermined. 


DISEASES  OF  THE  DIGESTIVE  TRACT.  207 

Symptomatology. — The  symptoms  are  out  of  all  proportion  to  the 
anatomical  lesions  which  are  found  at  necropsy.  A  child  apparently 
quite  well  or  only  ill  from  a  digestive  disturbance  suddenly  begins 
to  vomit  and  has  a  rise  of  temperature.  A  profuse  diarrhea  follows, 
possessing  the  characteristics  of  decomposition  with  very  foul-smelling 
stools.  The  stomach  and  intestinal  contents  are  at  first  expelled  in 
this  manner.  The  vomiting  then  consists  of  a  watery  fluid  with  flakes 
of  mucus.  The  stools  also  now  lose  their  fecal  character,  and  are 
watery,  greenish-gray  in  color,  w^ith  a  peculiar  old  musty  odor  which 
is  quite  characteristic.  These  discharges  at  first  copious  and  explosive 
become  smaller  in  amount  but  very  frequent;  they  consist  of  serum  and 
mucus,  and  may  be  as  many  as  twenty  or  thirty  a  day.  In  some  cases 
there  is  an  almost  constant  oozing  from  the  anal  ring.  The  vomiting 
and  diarrh9a  with  the  high  temperature  causes  a  quick  collapse  and  an 
emaciation  which  is  extremely  rapid,  due  to  the  character  of  the  dis- 
charge which  is  largely  blood  serum.  The  extremities  are  cold,  the 
pulse  feeble,  the  respirations  shallow  and  sighing,  and  the  infant  lies 
in  a  semicoma.  Thirst  is  extreme,  and  water  is  eagerly  taken.  Men- 
ingitic  symptoms  supervene,  with  delirium,  twitching,  purposeless 
movements  or  convulsions.  Unless  the  progress  of  the  disease  is 
arrested,  the  temperature  rises  to  105°  or  107°  F.,  with  coma  and 
death  resulting  from  cardiac  exhaustion  at  the  end  of  the  second  or 
third  day.  If  the  treatment  has  been  successful,  the  convalescence 
is  extremely  slow  and  demands  incessant  care. 

Course  and  Prognosis. — This  should  always  be  given  as  extremely 
bad.  If  prostration  comes  on  rapidly,  with  high  temperature  and 
nervous  symptoms,  the  course  is  often  not  longer  than  twenty-four 
hours. 

Treatment. — -This  must  be  energetic  and  heroic  if  any  good  is  to 
be  accomplished.  Gastric  lavage  with  warm  saline  solution  should 
be  made  if  the  patient  is  seen  early.  If  prostration  is  apparent,  stimu- 
lation is  the  first  indication,  and  is  here  best  obtained  by  the  use  of  hypo- 
dermoclysis  which  supplies  the  tissues  with  fluid  and  likewise  stimu- 
lates. Inject  eight  to  ten  ounces  into  the  subcutaneous  tissue  of  the 
abdomen — using  for  this  purpose  sterile  normal  saline  solution  (6  grs. 
to  the  liter)  and  repeat  this  every  four  to  six  hours.  Enemas  of  nor- 
mal salt  solution  may  also  be  employed.  For  a  very  rapid  effect  a 
hypodermatic  injection  of  atropin  gr.  ^^^  is  efficacious,  acting  also  as  a 
check  to  the  serous  waste.  This  may  be  repeated  every  three  hours 
if  necessary.  Camphor  in  sterile  olive  oil  (one  grain  of  camphor  to 
every  ten  minims  of  oil)  may  be  injected  in  the  intervals,  if  the  cardiac 
action  is  feeble.     Immersion  in  warm  baths  at  blood  heat,  or  at  1 10°  F. 


208  DISEASES  OF  CHILDREN. 

if  the  temperature  should  suddenly  drop,  is  efficacious.  They  should 
be  continued  for  a  half-hour,  and  repeated  at  three-hour  intervals; 
gentle  friction  and  the  addition  of  mustard,  one  tablespoonful  to  the 
bath,  will  assist  in  keeping  the  extremities  warm.  No  food  is  permitted 
and  no  medicines  should  be  administered  by  mouth  until  the  danger 
of  death  from  collapse  is  past.  Should  the  child  rally,  cautious  feed- 
ings and  medication  as  outlined  under  the  article  on  Summer  Diarrhea, 
is  to  be  followed  under  the  supervision  of  a  competent  nurse.  As 
soon  as  possible  thereafter  a  change  to  the  seaside  should  be  made. 

Constipation. 

This  should  be  regarded  as  a  symptom  and  not  a  disease,  and 
accordingly  the  underlying  cause  should  be  sought  for  and  corrected. 

Etiology.  Rare  Causes. — The  condition  may  be  caused  by  con- 
genital anatomical  abnormalities,  by  new  growths,  or  by  the  dispro- 
portionate length  of  the  sigmoid  flexure.  Adhesive  peritonitis  (espe- 
cially the  tuberculous  variety)  also  causes  constipation. 

The  commoner  causes  are  mainly  dietetic.  Artificially  fed  infants 
are  the  most  frequent  sufferers  because  of  badly  balanced  food  mix- 
tures (see  Artificial  Feeding,  p.  153),  either  too  large  or  too  small  an 
amount  of  one  ingredient  of  the  milk,  or  the  boiling  of  the  milk  itself 
acting  as  causes.  Breast-fed  infants  are  constipated  from  deficiency 
in  the  fat  or  total  quantity  of  solids  present  in  the  mother's  milk. 
In  older  children  a  badly  arranged  dietary,  especially  a  deficiency  in 
the  carbohydrates  and  fruit  juices,  will  cause  this  symptom.  Next  to 
the  diet,  the  lack  of  training  of  the  child  is  an  important  cause  in  pro- 
ducing constipation.  Children  who  suffer  from  constitutional  diseases, 
such  as  rickets  and  infantile  atrophy,  may  be  constipated  because  of 
the  lack  of  expulsive  power  and  deficient  peristaltic  action. 

Other  causes  are  deficiency  of  the  intestinal  and  biliary  secretions, 
nervous  inhibition  of  the  normal  peristalsis  in  such  diseases  as  menin- 
gitis, and  intestinal  parasites.  The  fear  of  causing  pain  when  at 
stool,  as  from  fissures  of  the  anus,  may  lead  to  constipation. 

Symptomatology.  In  Infancy. — Colicky  pains  and  flatulence 
precede  the  passage  of  the  fecal  mass,  which  is  hard  and  dry  or  putty- 
like. Absorption  of  the  toxins  may  cause  rise  of  temperature  or 
possibly  convulsions.  These  infants  are  inclined  to  be  fretful  with  ca- 
pricious appetites  and  are  poor  sleepers.  They  are  likewise  inclined  to 
eczema.     Rectal  examination  will  reveal  the  fecal  masses. 

In  Older  Children. — The  tongue  is  coated,  the  breath  is  foul,  and 
there  is  lassitude  and  depression  with  headache.     There  may  be  a 


DISEASES  OF  THE  DIGESTIVE  TRACT.  209 

slight  rise  of  temperature,  and  the  complexion  becomes  sallow  or  pasty. 
The  appetite  is  lost.  Sleep  is  disturbed.  The  stools  are  passed  with 
an  effort,  may  be  mucus-coated  and  exceptionally  large  and  ball-like. 
The  child  may  go  for  several  days  without  a  movement.  Digital 
examination  will  clear  up  any  doubtful  case. 

Treatment. — With  persistent  and  patient  effort  all  cases  can  bq 
cured.  The  food  taken  by  the  child  must  be  studied  and  the  error 
which  is  usually  dietetic  set  right.  Medicines  should  have  a  minor 
place;  the  main  reliance  should  be  on  diet,  correct  habits,  and  massage. 
Deficiency  in  the  total  amount  or  irregularity  of  any  of  the  food 
components  must  be  properly  balanced.  If  the  fats  are  deficient 
in  the  mother  attempt  should  be  made  to  improve  the  milk  by  dietetic 
and  hygienic  measures,  and  by  regulating  the  amount  of  sleep  and 
exercise.  If  this  fails,  alternate  feedings  or  supplementary  feedings 
of  modified  milk  may  be  given.  Nursing  mothers  should  be  placed 
on  a  diet  list  which  w^ould  include  plenty  of  clean  raw  milk,  corn- 
meal  gruel,  and  water  between  meals.  Feeble  infants  in  whom  the 
efforts  to  expel  the  mass  are  unsuccessful,  as  is  evi- 
denced by  the  finger  in  the  rectum,  are  helped  by 
gentle  massage  of  the  abdomen,  the  introduction  of  a 
gluten  suppository  or  the  nipple  of  a  rectal  syringe. 
Artificially  fed  babies  are  most  often  constipated  be- 
cause they  are  usually  on  a  modified  food  incorrectly 
ordered.  See  to  it  that  there  is  a  sufficiency  of  fat 
and  protein  in  the  mixture  and  that  the  curd  is 
mechanically  broken  up  by  the  addition  of  a  gruel. 
Oatmeal  gruel  may  be  tried  in  infants  suffering  from 
constipation.  Water  between  the  feedings  must  be 
offered  freely.  A  tablespoonful  or  two  of  orange  or 
pineapple  juice  is  decidedly  beneficial  in  infants  after 
the  first  six  months  of  life.  Beef  juice  or  chicken 
broth  are  laxative  and  may  be  judiciously  employed.  Fig.  59. — Rec- 
If  the  mixture  has  been  made  up  with  a  proprietary  infants'  ^^ 
infant  food,  this  should  be  changed.  If  the  constipa- 
tion has  been  neglected  for  some  time  it  may  be  necessary  to  use  soap 
enemata,  four  to  eight  ounces  at  a  time.  Glycerin  suppositories  at 
first  may  be  tried  in  conjunction  with  a  proper  diet  and  hygienic 
measures,  and  then  gradually  use  milder  procedures  as  improvement 
takes  place.  By  simpler  procedures  is  meant  the  injection  of  a  few 
drams  of  olive  oil  or  an  ounce  of  warm  water  with  a  baby  rectal 
syringe. 

The  elixir  of  cascara  sagrada  (N  F.)  ten  to  thirty  drops  may  be 
14 


210  DISEASES  OF  CHILDREN. 

prescribed,  or  malt  and  cascara  given  in  the  miminum  dosage  possible 
to  produce  a  satisfactory  movement  (one-half  to  one  teaspoonful). 
As  soon  as  the  supplementary  measures  can  be  depended  upon,  the 
medicines  should  be  abandoned  altogether. 

A  regular  stooling  habit  can  be  cultivated  almost  from  infancy 
by  placing  the  baby  on  a  small  commode  at  regular  intervals  and  is 
a  prophylactic  measure  of  importance  in  child  life. 

The  constipation  of  older  children  may  be  corrected  by  the 
addition  of  cream  and  butter  to  the  food,  or  in  other  instances,  a 
greater  amount  of  vegetables  and  fruit  must  be  ordered.  Taking  a 
glass  of  water  on  arising,  followed  by  a  cold  sponging  and  abdominal 
massage  will  cure  many  cases  if  regularly  carried  out,  besides  im- 
proving the  general  body  tone  and  blood-supply.  Calomel,  castor 
oil  or  the  salts  should  not  be  given  for  this  condition.  They  are 
cathartic  in  action  and  tend  to  produce  constipation. 


^ft 


%, 


PLATE  III 


Ova  of  the  cestodes  of  early  life.  Tenia  solium  (Pork  tape-worm),  p-p';  Tenia 
saginata  (Beef  tape-worm),  q-q';  Bothriocephalus  latus  (Fish  tape- worm),  k-k'; 
Uncinaria  americana  (Hook-worm),  x-x'-x"-x"';  Ascaris  lumbricoides  (Round- 
worm), y-y";  Oxyuris  vermicularis  (Thread  worm),  d-d'-d"-d"'. 


CHAPTER  XX. 

THE  ANIMAL  PARASITES. 

These  may  be  conveniently  divided  into  several  groups  and  sub- 
groups (see  table  below).  Only  those  that  are  found  with  some 
frequency  in  childhood  will  be  described  and  pictured. 

Parasitic  Protozoa. 

Animal  Parasites  Found  in  Childhood: 

Nematodes. — Oxyuris  vermicularis  (thread  worm).  Ascaris  lum- 
bricoides  (round  worm).  Trichina  spiralis.  Ankylostoma  americana 
(hook  worm). 

Ces^orfes.— Tenia  saginata.  Tenia  solium  (pork  tape-worm). 
Bothriocephalus  latus. 

Although  infection  is  more  frequent  with  intestinal  parasites 
among  children  than  in  adults,  the  cases  are  mainly  found  in  the  off- 
spring of  foreigners  in  this  country. 

These  parasites  are  taken  to  be  the  cause  of  many  of  the  ailments 
of  children  by  parents  frequenting  the  dispensaries  and  many  of  them 
have  been  given  the  therapeutic  test  without  any  clinical  evidence  of 
the  parasites  being  present.  When  they  are  present  in  any  quantities 
they  may  do  harm,  especially  in  sickly  children,  by  impoverishing 
the  albumin  content,  by  acting  as  foreign  bodies  in  unusual  sites, 
and  by  poisoning  their  host  through  their  metabolic  products.  The 
evil  effect  of  intestinal  parasites  is  often  exaggerated  in  the  mother's 
mind. 

Oxyuris  Vermicularis. 

{Thread  Worms.) 

These  are  small  white  filament-like  worms  usually  found  in  the 
rectum.  The  female  is  larger  than  the  male,  and  usually  is  found 
in  the  cecum,  until  impregnated,  when  it  descends  to  the  rectum. 

The  eggs  are  oval,  asymmetrical,  about  0.05  mm.  in  size 
Their  interior  is  filled  with  a  granular  yolk,  containing  a  clear 
nucleus.  The  oxyuris  differs  from  some  of  the  other  parasites 
in  that  it  does  not  require  an  intermediary  host.  The  worms  and 
the  eggs  pass  out  of  the  rectum  alone  or  with  the  feces,  and  may 

211 


212 


DISEASES  OF  CHILDREN. 


directly  inoculate  a  human  body.     The  child  may  reinfect  itself  by 
handling  toys,  or  food,  and  may  infect  its  playmates. 

Symptomatology. — The  worms  by  their  presence  may  produce 
irritation  of  the  anus,  or  if  present  in  sufficient  numbers,  even  a  colitis 
or  proctitis  may  result.     The  children  sleep  poorly  and  scratch  about 

the  anus.  They  lose  their  appetites,  be- 
come irritable,  and  even  anemic.  In  girls, 
particularly,  the  parasites  may  invade  the 
genitals,  and  result  in  masturbation  or 
incontinence  of  urine.  Sometimes  no 
symptoms  are  to  be  noted. 

Diagnosis. — An  enema  of  cold  water 
will  disclose  any  parasites  present  if  they 
are  not  found  in  the  stools  or  at  the  anus. 
The  eggs  are  found  with  difficulty  in  the 
stools;  more  often  they  are  found  under 
the  finger-nails  of  the  infected  child. 

Treatment.  Prophylactic. — By  atten- 
tion to  the  person  of  the  patient,  self-in- 
oculation can  and  must  be  prevented. 
Baths,  clean  finger-nails,  restrictive  ap- 
paratus for  the  hands  or  heavy  canvas 
drawers  to  prevent  scratching  are  some- 
times necessary.  Examine  other  suscep- 
tible members  of  the  family  to  prevent 
reinfection. 

Internal. — A  grain  of  calomel  or  a  tea- 
spoonful  of  Rochelle  salts  in  water  is  given 
to  bring  down  the  females  from  the  cecum. 
Locally. — Daily  enemata  of  saline 
solution  may  be  given  followed  three 
times  a  week  by  injections  of  the  infusion 
of  quassia,  this  to  be  retained  for  a  time 
if  possible.  Further,  a  2  per  cent,  yellow 
oxid  of  mercury  ointment  is  applied  about  and  into  the  rectum  at  night. 
This  treatment  should  be  persisted  in  until  the  bowel  is  thoroughly 
rid  of  the  worms,  and  renewed  if  any  are  seen  at  a  later  date. 


Fig.  60. — Oxyuris  vermicu- 
laris.  a,  Sexually  mature 
female;  b,  female  with  eggs; 
c,  male.     (After  Heller.) 


Ascaris  Lumbricoides. 

(Round  Worm.) 
This  parasite  is  round  with  a  smooth  body  from  four  to  six  inches 
long  and  pointed  at  each  end.     The  mouth  has  three  suckers  and  teeth. 


THE  ANIMAL  PARASITES. 


213 


The  female  is  very  prolific,  producing 
millions  of  eggs.  These  are  rounded 
or  oval  in  shape  (see  Fig.  61).  It  has 
been  proven  by  experimentation  that 
no  intermediary  host  is  necessary. 
Although  they  normally  inhabit  the 
small  intestine,  they  move  from  place 
to  place.  They  have  been  frequently 
vomited  from  the  stomach  and  have 
been  found  in  the  gall-bladder  and 
appendix  in  children.  Through  its 
ova  it  gains  entrance  to  the  human 
intestinal  canal. 

Symptomatology. — The  parents 
themselves  often  make  the  diagnosis 
of  round  worms  when  they  have  seen 
them  passed.  When  questioned  the 
majority  of  the  patients  do  not  give 
any  symptoms  directly  referable  to 
the  worms,  and  many  have  had  no 
symptoms  whatever.  The  symptoms 
usually  present  are  loss  of  appetite, 
nausea,  or  diarrhea,  occasionally  there 
are  pains  referable  to  the  abdomen, 
which  are  soon  forgotten,  only  to 
reappear  again.  Pruritus  ani,  pavor 
nocturnus,  choreiform  movements, 
and  convulsions  have  been  observed. 
A  rather  constant  eosinophilia  is  pres- 
ent in  patients  with  round  worms,  and 
this  should  be  a  stimulus  to  examine 
the  feces  for  ova.  By  their  local 
action  or  migration  they  may  produce 
obstruction  of  the  intestine  or  even  a 
fatal  issue,  as  in  laryngeal  obstruction. 

Diagnosis. — The  microscopic  ex- 
amination for  the  ova  is  readily  made 
and  should  not  be  omitted  in  ques- 
tionable cases  having  an  eosinophilia. 

Treatment.  Prophylactic. — 
Cleanliness  of  body,  a  pure  water- 
supply,    and    avoidance  of   unboiled 


Fig.  61. — Ascaris  lumbri- 
coides.  A,  A  female;  B,  a  male, 
natural  size;  fe,  cephalic  end,  en- 
larged, showing  lips.  {After 
Peris.) 


214 


DISEASES  OF  CHILDREN, 


vegetables  for  children  decrease  the  possibility  of  infection.  Care  in  the 
handling  of  the  stools  of  children  will  also  prevent  infection  of  others. 
Internal. — Calomel  and  santonin  is  a  dependable  combination 
for  this  parasite.  A  half-grain  of  each  drug  with  sugar  of  milk  is  usu- 
ally sufficient.  Never  give  more  than  a  grain  of  santonin,  as  poisoning 
may  be  produced.  It  is  best  given  with  some  food  and  in  divided 
doses.  The  stools  should  be  examined  for  ova  each  week  for  three 
weeks,  as  until  then  there  is  no  positive  certainty  of  their  absence. 

Cestodes,  or  Tape -worms. 

General  Characteristics. — The  tape-worms  commonly  met  with  in 
this  country  in  children  are  the  Tenia  mediocanellata  (or  saginata)  or 
beef  tape-worm,  and  the  Tenia  solium  or  the  pork  tape-worm.  They 
are  flat,  ribbon-like,  jointed  parasites,  yellowish  in  color,  and  vary  in 


Fig.  62. — Head  of  Tenia  sagi- 
nata, much  magnified. 


Fig.  tj3. — Head  of  Tenia 
solium,  showing  scolex, 
suckers,  hooks,  and  neck. 


length  from  ten  to  twenty  feet,  the  segments  growing  smaller  until  the 
head  is  reached.  It  is  only  in  the  intestinal  tract  of  man  that  the  fully 
developed  parasite  is  found.  The  ova  are  taken  into  the  alimentary 
tract  of  an  animal  and  their  covering  is  dissolved  and  they  then  pass 
through  into  the  muscles  of  the  animal  and  become  encysted  there. 
Such  meat  is  commonly  spoken  of  as  being  "measly."  This  infected 
meat  when  eaten  by  man  allows  the  larvae  to  develop  into  the  tape- 
worm. Although  occurring  rarely,  man  may  himself  act  as  the  inter- 
mediary host  and  cysticerci  develop  in  his  organs. 


THE  ANIMAL  PARASITES. 


215 


Tenia  Mediocanellata  or  Saginata  {The  Beef  Tape-worm). 

These  worms  may  be  distinguished  by  the  appearance  of  their 
heads  under  the  magnifying  glass.  The  head  of  the  beef  worm  is 
cuboid,  sHghtly  darker  than  the  rest  of  the  body  and  it  has  no  hooks 
as  the  pork  worm  has;  instead  four  suckers 
are  seen  on  the  head.  Its  eggs  are  smaller 
than  that  of  the  Tenia  solium,  and  contain 
booklets. 

Tenia  Solium  (The  Pork  Tape-worm  or  • 
the  Armed  Tape-worm). 

The  head  of  this  parasite  which  is  about 
the  size  of  a  pin-head,  has  besides  the  four 
suckers  found  on  the  beef  worm,  a  set  of 
booklets.  They  often  reach  nine  feet  in 
length.  The  eggs  are  round  and  contain 
the  embryo  with  its  booklets. 

Symptomatology. — In  the  great  major- 
ity of  cases  there  are  no  pathognomonic 
symptoms  referable  to  the  teniae.  Often  it 
is  only  when  the  segments  are  passed  that 
their  presence  is  indicated.  Older  children 
may  complain  of  grumbling,  griping  pains, 
and  have  symptoms  of  indigestion.  They 
become  anemic,  have  headaches,  and  com- 
plain of  dizziness.  Sometimes  a  capricious 
or  voracious  appetite  may  excite  suspicion, 
if  coupled  with  a  history  of  eating  raw  beef 
or  pork. 

Treatment.  Prophylactic. — Proper 
meat  inspection  at  the  abattoir.  A  dis- 
semination of  the  harm  that  may  be  caused 
by  eating  of  raw  or  badly  cooked  meats 
and  destruction  by  fire  of  all  segments 
passed  would  materially  reduce  the  number 
of  these  cases.  The  children  of  foreigners 
are  especially  to  be  warned. 

Internal. — The  parasites  can  be  removed  if  a  systematic  cure  is 
outHned  and  rigidly  followed,  as  the  head  is  firmly  attached  and  must 
be  dislodged  to  effect  a  cure.  First  day:  a  dose  of  castor  oil,  at  least 
a  half  ounce,  is  given,  followed  by  fasting  for  the  remainder  of  the  day. 


Fig.  64. — Portions  of  a  Tenia 
saginata.  (After  Leuckart, 
natural  size.) 


216 


DISEASES  OF  CHILDREN. 


Second  day:  following  a  cup  of  clear  consomme  or  weak  tea,  give 
the  following  prescription  for  a  five  year  old  child,  while  the  child  is 
kept  in  bed. 

Oleoresinse  aspidii 5  j 

Mucilaginis  acacise oij 

Spirit!  chloroformi rr^x 

Aquae  cinnamomi    q.s.  ad.  5  j 

Misce  et  Sig. — Oae-half  tlie  quantity  at  a  dose. 

The  remainder  is  given  after  a  few  hours,  if  the  child  should  vomit 
the  first  dose;  they  rarely  reject  the  second,  if  kept  prone  in  bed. 

Several  hours  after  the  vermifuge  has  been 
given,  a  glass  of  the  effervescent  citrate  of  magnesia 
is  taken.  The  worm  should  be  passed  into  a  clean 
vessel,  containing  warm  water,  and  careful  examina- 
tion made  for  the  head,  for  unless  this  is  identified, 
the  cure  will  be  unsuccessful. 

This  treatment  has  been  so  successful  in  our 
hands,  that  there  has  been  no  necessity  to  resort  to 
less  reliable  vermifuges,  as  the  pelleterine  tannate, 
kousso,  kamala,  etc. 

Uncinaria  Duodenalis. 

(Ankylostomum  Duodenale  or  Hook 
Worm). 

This  parasite  has  assumed  a  greater  interest 
for  us  in  the  past  few  years  because  of  our  new 
possessions  in  the  West  Indies,  and  since  the  pub- 
lication of  the  investigations  of  Stiles  who  has 
shown  how  prevalent  they  are  in  the  children  of 
the  Southern  States. 

The  hook  worms  are  small  thread-like  parasites 
with  four  teeth  which  enable  it  to  attach  itself  to 
the  intestine.  The  jejunum  being  its  favorite  site. 
The  eggs  develop  rapidly  and  the  embryos  are  very  tenacious  of  life. 
The  eggs  are  oval  in  shape,  with  a  distinct  capsule  and  a  brownish  con- 
tent. Unclean  water,  the  eating  of  raw  vegetables,  and  unclean  hands 
and  bare  feet  are  the  means  through  which  infection  takes  place.  - 

Symptomatology. — The  children  having  hook  worms  are  pasty, 
white  and  thin.  The  appetite  is  abnormal;  mainly  a  craving  for  the 
unusual.     The  anemia  is  marked,  so  that  the  patient  is  listless,  without 


Fig.  65. — Unci- 
naria d  u  o  d  e  n  a  I  is. 
(Aftei  Loss,  X  105.) 


THE  ANIMAL  PARASITES. 


217 


ambition,  and  mentally  dull.  Later  the  abdomen  becomes  prominent 
and  there  is  edema  of  the  extremities.  The  stools  if  examined  show 
the  ova. 

Treatment. — Thymol  is  almost  a  specific  for  the  hook  worm. 
The  bowels  should  be  emptied  with  calomel  or  castor  oil,  the  diet 
restricted,  and  thymol  given  in  five-grain  doses  every  two  to  three 
hours  until  twenty  grains  of  the  solid  drug  are  taken.  Another  purge 
should  now  be  administered  or  a  high  enema  given.  Weekly  exami- 
nations of  the  stools  should  be  made,  and  if  any  are  found,  repeat  the 
cure  each  week.  Following  the  elimination  of  the  ova,  an  iron  pep- 
tonate  should  be  prescribed  until  the  hemoglobin  content  is  normal. 


Fig.  6tj. — Oral  capsule  of  Uncinaria  duodenalis. 


Trichina  Spiralis. 

Children  are  liable  to  infection  from  this  parasite  by  eating 
diseased  pork.  Those  living  in  country  districts  where  the  curing  of 
the  pork  is  done  at  the  farmer's  home  are  especially  liable.  The 
encapsulated  trichinae  are  freed  in  the  stomach,  propagate  and  deposit 
living  embryos.  Those  which  are  not  passed  out  of  the  intestinal 
canal,  reach  the  muscles  where  they  develop  and  finally  become 
encapsulated. 

Symptomatology. — During  the  first  week  of  their  ingestion  the 
symptoms  are  slight  and  those  of  a  gastrointestinal  nature.  Then 
general  muscular  pains  with  high  fever  develop  and  are  often  mistaken 
for  rheumatism  or  typhoid.  Transitory  swellings  appear.  The 
muscles  are  painful  to  the  touch;  nausea  and  vomiting  or  diarrhea 
may  be  present.  Dysphagia  prohibits  the  taking  of  nourishment. 
Stupor  and  coma  may  ensue  in  fatal  cases.  Eosinophilia  is  marked 
and  is  a  distinct  aid  to  the  diagnosis. 

Treatment.  Prophylactic. — Reliable  meat  inspection  and  thorough 
cooking  of  all  hog  meat  (200°  F.  are  necessary  to  kill  encapsulated 


218  DISEASES  OF  CHILDREN. 

trichinae)  are  measures  of  prophylaxis  which  are  self  evident.  Better 
still,  pork  in  any  form  should  be  prohibited  in  the  dietary  of  the  child. 
Internal. — Calomel  is  given  until  free  purgation  is  obtained. 
Benzol  is  then  administered  in  grain  doses,  alternating  with  glycerin 
half  a  dram  every  four  hours.  Good  nursing  is  necessary  to  keep  up 
the  strength  of  the  patient  through  long  convalescence. 


Fig.  67. — Encapsulated  muscle  trichina;.     {After  Leuckart,  X  10.) 


CHAPTER  XXI. 
DISEASES  OF  THE  LIVER. 

The  Liver. 

The  hver  is  of  relatively  large  size  and  functional  importance  in 
early  life.  In  fetal  life  it  is  a  very  important  factor  in  the  circulatory 
system,  while  the  lungs  are  largely  inactive.  Thus  in  the  mature 
fetus  the  liver  holds  a  quarter  or  more  of  the  entire  volume  of  blood, 
and  it  is  greater  in  size  than  both  lungs.  As  the  lungs  of  the  fetus  are 
solid,  and  almost  impervious,  the  placenta  of  the  mother  performs 
the  double  function  of  a  respiratory  and  of  a  nutritive  organ.  After 
the  venous  blood  is  received  from  the  fetus  it  must  be  returned  reoxy- 
genated,  and  nearly  the  whole  of  this  purified  stream  is  carried  to  the 
liver  by  the  umbilical  vein  and  circulates  through  this  organ  before 
reaching  the  vena  cava  and  the  general  circulation.  The  large  size 
and  importance  of  the  liver  in  fetal  life  are  thus  understood  by  con- 
sidering it  a  sort  of  intermediary  organ  between  the  placenta  and  the 
general  circulation,  as  far  as  the  reoxygenated  blood  is  concerned. 
At  birth  the  lungs  should  at  once  inflate  and  assume  the  respiratory 
function.  The  umbilical  vein  is  completely  obliterated  in  a  few  days 
and  finally  becomes  the  round  ligament  of  the  liver  and  the  ductus 
venosus  is  likewise  obliterated.  Although  the  liver  now  loses  its 
preponderating  importance  in  the  economy,  it  still  remains  relatively 
larger  and  heavier  than  in  later  life.  The  diminution  of  the  organ  is  due 
to  its  altered  blood  supply,  and  is  especially  marked  in  the  left  lobe. 
The  loss  of  weight  that  begins  at  birth  continues,  so  that  there  is  a 
direct  ratio  from  infancy  to  old  age  in  this  relative  diminution.  In 
infancy  the  liver  weight  is  in  proportion  to  the  whole  body  as  one  to 
twenty;  at  puberty,  one  to  thirty;  in  adult  life,  one  to  thirty-five;  in 
middle  life,  one  to  forty;  in  old  age,  one  to  forty-five. 

Examination  of  the  Liver. 

The  child  is  placed  in  the  recumbent  position  with  the  thighs 
flexed  in  order  to  relax  the  abdominal  muscles  as  much  as  possible. 
The  organ  may  then  be  mapped  out  by  palpation  and  percussion. 
The  liver  projects  from  h  inch  to  1  inch  below  the  free  borders  of  the 

219 


220  DISEASES  OF  CHILDREN. 

ribs.  In  the  median  line  the  lower  border  of  the  left  lobe  extends  to 
within  about  an  inch  of  the  umbilicus.  It  must  be  borne  in  mind 
that  the  liver  ascends  and  descends  with  full  inspiration  and  expira- 
tion. If  the  organ  is  enlarged  it  can  be  detected  by  deep  palpation, 
and  effort  should  be  made  to  map  out  the  seat  and  character  of  the 
swelling. 

On  percussion,  liver  dullness  along  the  upper  border  will  begin 
at  the  right  sternal  margin  and  in  the  mammary  line  in  the  fifth  inter- 
costal space,  in  the  axillary  line  at  the  seventh  rib,  and  in  the  scapular 
region  at  the  ninth  rib.  Upon  very  light  percussion,  the  dullness 
will  be  noted  a  little  below  these  lines. 

Apparent  enlargement  of  the  liver  may  be  caused  by  a  slight 
displacement  induced  by  the  bony  deformity  of  the  thorax  in  rickets, 
by  effusion  in  the  right  pleural  cavity,  by  tumor  of  the  right  kidney, 
by  fluid  in  the  abdominal  cavity,  or  by  subphrenic  abscess.  The 
commonest  causes  of  true  enlargement  of  the  liver  in  early  life  are 
abscess,  fatty  degeneration,  cirrhosis,  and  leukemia. 

Jaundice. 

Icterus  neonatorum  has  been  considered  in  the  section  on  Diseases 
of  the  Newly-born.  In  attacking  infants  some  time  after  birth 
j  aundice  is  due  to  causes  similar  to  those  found  in  children  and  adults. 
Owing  to  some  obstruction  in  the  biliary  canals,  the  bile,  instead  of 
passing  into  the  intestine,  is  absorbed  into  the  blood. 

An  inflammation  of  the  duodenum,  accompanied  by  swelling 
of  the  mucous  membrane  at  the  opening  of  the  ductus  communis 
choledochus,  may  be  responsible  for  this  obstruction.  The  inflamma- 
tion may  also  extend  by  direct  continuity  from  the  duodenum  to  the 
ductus  communis  and  hepatic  ducts,  and  thus  cause  retention  of  bile  in 
the  liver. 

A  plug  of  inspissated  bile  in  the  common  duct,  and,  more  rarely, 
gall-stones  may  also  cause  obstruction.  Complete  stoppage  has  been 
reported  by  a  round  worm  penetrating  the  common  duct  from  the 
duodenum. 

Inflammatory  changes  in  the  liver,  as  in  cirrhosis,  may  induce 
jaundice  by  obstruction  from  pressure  in  the  intrahepatic  ducts. 
Finally,  certain  toxic  conditions,,  as  in  paludism  and  various 
infectious  diseases,  and  rarely  phosphorous  poisoning  may  act  as 
causes. 

Symptomatology. — The  most  objective  sign  is  the  general  yellow- 
ness of  the  skin  and  the  conjunctivae.     Other  abnormal  tints  of  the 


DISEASES  OF  THE  LIVER.  221 

skin  simulating  jaundice  may  be  differentiated  by  the  yellow  conjunc- 
tivae and  by  the  presence  of  biliary  pigment  in  the  urine. 

Itching  of  the  skin  may  be  present.  Urticaria,  which  is  so  com- 
mon in  children,  sometimes  ensues  when  the  papules  and  wheals  will 
present  a  deep-yellow  tint.  The  yellowness  of  the  skin  is  usually  only 
to  be  noted  in  a  natural  light. 

The  most  marked  internal  symptoms  may  be  those  that  can  be 
referred  to  a  duodenitis  or  a  gastroduodenitis.  In  the  latter  case 
there  is  more  or  less  nausea  and  vomiting,  with  pain  in  the  epigastrium, 
especially  upon  the  ingestion  of  food  and  tenderness  upon  pressure 
in  this  region. 

There  may  be  a  subacute  duodenitis  without  gastritis  being 
present,  when  pain  will  be  noted  some  hours  after  taking  food  as  it 
passes  from  the  stomach  into  the  duodenum.  The  stools  may  be  clay 
colored  from  an  excess  of  undigested  fat  when  no  bile  reaches  the  in- 
testine. When  the  obstruction  to  the  passage  of  bile  is  only  partial 
the  stools  may  retain  a  natural  brownish-yellow  color.  The  complete 
absence  of  bile  will  be  shown  by  a  quick  decomposition  of  the  intestinal 
contents  as  exhibited  in  the  free  formation  of  gases  and  a  foul  odor  of 
the  feces. 

The  pulse  may  be  slow  as  the  biliary  salts  have  a  sedative  effect 
on  the  circulation.  Most  cases  of  jaundice  in  young  children  disap- 
pear in  a  few  weeks  without  leaving  any  serious  consequences,  but 
rarely  there  may  suddenly  ensue  evidences  of  blood-poisoning, 
followed  by  death.  Occasionally  the  jaundice  will  last  for  months 
without  giving  rise  to  much  apparent  disturbance  except  a  slight 
stupidity. 

Treatment. — Where  there  is  no  evidence  of  gastroduodenal  in- 
flammation, active  peristaltic  action  in  the  duodenum  to  be  trans- 
mitted to  the  bile  ducts  may  be  induced  by  calomel,  rhubarb,  aloes,  or 
colocynth.  This  may  be  followed  by  a  mixture  containing  tincture 
nucis  vomicsB  with  bicarbonate  of  potassium  or  sodium,  as  alkalies  are 
supposed  to  have'  a  liquefying  effect  upon  the  bile,  thus  freeing  the 
ducts  when  they  are  occluded  by  a  thickening  of  this  secretion. 

Only  bland  and  easily-digested  food  must  be  allowed.  All  fatty 
foods  must  be  restricted  and  the  patient  kept  on  lean  meat  and  plain 
vegetable  food. 

When  the  jaundice  depends  on  a  subacute  inflammation  of  the 
stomach  and  duodenum,  the  saline  laxatives  and  mineral  waters  do 
well.  Carlsbad,  Vichy,  and  Congress  waters  usually  are  beneficial. 
Persistent  constipation  is  one  of  the  commonest  sjmiptoms,  and  must 
alwavs  be  relieved. 


222  DISEASES  OF  CHILDREN. 

InlOlammation  of  the  Biliary  Ducts. 

An  ordinary  acu,te  inflammation  of  the  biUary  ducts  usually  under- 
goes resolution  in  a  few  weeks  without  any  bad  results  being  left  behind. 
As  a  result  of  the  inflammation  a  collection  of  mucus,  often  taking 
the  form  of  a  firm  plug,  is  Ib'cated'af  t^e  opening  of  the  common  duct 
into  the  duodenum,  thus  causing  more  or  less  complete  obstruction. 

In  chronic  cases  there  may' result  a  thickening  of  the  ducts,  with 
dilation  in  places  caused  by  the  obstructed  secretions.  Rarely,  ulcera- 
tion may  take  place  in  the  walls  of  the  ducts.  The  mucous  membrane 
of  the  gall-bladder  may  likewise  be  the  seat  of  inflammatory  changes. 

Symptomatology. — Various  digestive  disturbances  shown  by 
coated  tongue,  nausea  or  vomiting,  and  other  symptoms  pointing  to  a 
mild  inflammation  of  the  stomach  are  present  at  the  start.  There 
may  be  slight  fever. 

In  a  few  days  the  conjunctivae  become  yellow,  the  urine  is  colored 
by  biliary  pigment,  and  the  feces  assume  a  clay-like  appearance. 
There  may  be  a  slight  enlargement  of  the  liver  and  the  gall-bladder 
may  be  palpated.  There  may  be  some  tenderness  on  pressure  over 
the  right  hypochondrium.  When  the  inflammation  of  the  ducts  is 
secondary  to  congestion  of  the  liver,  there  is  less  digestive  disturbance 
and  milder  jaundice  of  shorter  duration. 

The  treatment  is  the  same  as  that  of  jaundice.  Where  the  inflam- 
mation is  induced  by  changes  in  the  parenchyma  of  the  liver  or  by  certain 
infectious  diseases,  treatment  must  be  aimed  at  the  underlying  cause. 

Inflammation  of  the  Portal  Vein. 

Suppurative  pylephlebitis  may  occur  as  a  secondary  lesion  result- 
ing from  suppuration  in  some  of  the  organs  drained  by  the  portal 
vein  or  its  radicles.  Ulcerations  of  the  gastrointestinal  mucous  mem- 
brane, inflammation  or  ulceration  of  the  biliary  duct  and  umbilical 
phlebitis  in  new-born  infants  whose  mothers  are  septic  may  spread 
to  the  portal  system  and  set  up  inflammation  there. 

Symptomatology. — Local  pain  in  that  part  of  the  portal  vein 
involved  will  follow  the  symptoms  of  the  primary  morbid  condition. 
Enlargement  and  tenderness  of  the  liver  may  be  due  to  a  general  hepa- 
titis or  to  abscesses.  The  spleen  may  likewise  become  enlarged  and 
tender  from  occlusion  of  the  splenic  vein.  As  pus  forms  in  the  portal 
vein,  there  will  be  chills,  fever,  sweating,  and  general  emaciation. 
Intestinal  indigestion  with  bilious  stools  and  jaundice  usually  are 
present.  Although  there  may  be  remissions,  the  disease  usually  ends 
fatally  in  a  few  weeks. 


DISEASES  OF  THE  LIVER.  223 

Treatment. — All  that  can  be  done  is  to  treat  symptoms  as  they 
arise  and  sustain  the  strength  as  much  as  possible. 

Organic  diseases  of  the  liver  are  rare  in  early  life  and  do  not  differ 
essentially  from  adult  life. 

Congestion  of  the  Liver. 

This  condition  may  be  active  or  secondary.  The  active  form 
occurs  during  certain  infectious  diseases,  especially  paludism,  and  in 
the  early  stages  of  abscess  of  the  liver.  The  secondary  form  is  seen  in 
affections  of  the  heart  and  any  other  physical  condition  which  causes 
stagnation  in  the  liver  by  checking  the  access  of  blood  to  the  ascending 
vena  cava. 

The  organ  is  enlarged  in  both  forms,  but  more  so  in  the  cases  of 
passive  hyperemia.  There  is  usually  tenderness  on  pressure  over  the 
region  of  the  liver. 

The  treatment  must  be  addressed  to  the  disease  or  local  condition 
that  causes  the  congestion.  Phosphate  of  sodium,  citrate  of  magne- 
sium, and  other  saline  purgatives  may  be  given  to  try  and  deplete  the 
portal  circulation. 

Fatty  Liver. 

This  condition  may  be  present  in  various  constitutional  diseases, 
especially  rickets  and  tuberculosis.  It  is  more  often  secondary  to  the 
latter  disease  than  to  any  other.  Chronic  intestinal  disorders  and 
blood  dyscrasias  may  also  act  as  causes. 

The  organ  is  generally  uniformly  enlarged.  In  some  cases  the 
increase  in  size  is  very  great,  but  tenderness  is  absent.  There  are  usu- 
ally no  symptoms,  and  treatment  of  the  original  disease  is  all  that  can 
be  accomplished.  If  there  is  little  enlargement,  the  condition  cannot 
be  recognized  during  life,  but  it  is  seen  to  some  extent  in  a  large  num- 
ber of  the  autopsies  made  on  young  children. 

Amyloid  Liver. 

Waxy  liver  is  secondary  to  prolonged  suppuration  in  any  organ,  to 
chronic  joint  or  bone  disease,  to  tuberculosis  or  syphilis.  The  liver  is 
generally  enlarged,  with  a  hard,  rounded  border  and  free  from  pain  on 
pressure.  On  section,  it  gives  a  reddish-brown  reaction  with  iodin. 
Similar  changes  also  usually  develop  in  the  spleen  and  kidneys,  and 
the  spleen  is  thus  enlarged.  There  are  no  distinctive  liver  symptoms 
or  jaundice.     Albuminuria  may  be  present  from  the  kidney  affection, 


224  DISEASES  OF  CHILDREN. 

and  ascites  or  edema  from  pressure.  Gastrointestinal  irritation, 
shown  by  vomiting  and  the  passage  of  foul-smelling  stools  is  often 
noted.  When  waxy  liver  is  recognized,  it  means  some  form  of  chronic 
disease  and  a  grave  prognosis. 

The  treatment  consists  in  trying  to  check  the  original  focus  of 
suppuration,  in  supporting  the  patient,  and  in  handling  various  symp- 
toms as  they  arise. 

Cirrhosis  of  the  Liver. 

This  disease  is  rare  in  early  life  and  is  oftener  accompanied  by 
enlargement  than  contraction  of  the  liver.  The  commonest  primary 
causes  are  syphilis,  alcohol,  and  chronic  paludism.  Syphilitic  cirrhosis 
is  seen  in  early  infancy,  and  is  perhaps  the  commonest  form  of  organic 
disease  of  the  liver  at  this  time.  When  alcohol  acts  as  a  cause,  it  is  in 
older  children  of  from  ten  to  fifteen  years  of  age.  In  chronic  malarial 
poisoning,  there  is  great  enlargement  of  the  liver  when  this  organ  is 
the  seat  of  cirrhosis.  There  may  be  secondary  cirrhosis,  as  in  adults, 
from  hepatic  hyperemia  due  to  chronic  cardiac  disease,  from  prolonged 
obstruction  of  the  bile  ducts,  and  possibly  from  infectious  diseases,  such 
as  measles  and  scarlatina. 

The  pathology  and  symptoms  do  not  differ  from  cirrhosis  seen  in 
later  life.  It  is  often  difficult  to  recognize  the  disease  apart  from  the 
general  condition,  such  as  syphilis,  that  produces  it.  There  may  be  no 
symptoms  directly  referable  to  the  liver.  Icterus  may  or  may  not 
be  present,  but  enlarged  spleen  and  ascites  are  common. 

The  treatment  must  be  directed  to  the  primary  disease  and  various 
symptoms  as  they  arise. 

Abscess  of  the  Liver. 

Abscess  may  follow  suppuration  within  the  abdomen,  very 
rarely  from  the  migration  of  round  worms  through  the  common  duct, 
from  infectious  diseases,  and  in  the  newly-born  from  sepsis.  It  is 
very  rare,  however,  and  the  symptoms  are  similar  to  those  seen  in  the 
adult.     The  treatment  is  surgical. 

Acute  yellow  atrophy  and  gall-stones  occur  with  very  great 
rarity  in  early  life,  and  do  not  differ  in  course  and  symptoms  from  the 
same  affections  in  the  adult. 


SECTION  VI. 
THE  INFECTIOUS  DISEASES. 


CHAPTER  XXII. 
THE  EXANTHEMATA. 

The  exanthemata  consist  of  five  diseases:  scarlet  fever,  measles, 
German  measles,  small-pox  and  chicken-pox.  All  except  small-pox  are 
distinctively  diseases  of  childhood;  although  any  of  them  may  occur 
in  adults.  Each  runs  a  definite  self-limited  course,  subject  to  varia- 
tions and  complications.  As  a  rule,  each  renders  an  individual  im- 
mune to  future  attacks  of  the  same  disease,  but  one  does  not  confer 
immunity  from  another.  Two  of  them  may  occur  in  the  same  individ- 
ual at  the  same  time.  Each  is  divided  into  four  stages:  the  stage 
of  incubation,  prodromal  stage,  efflorescence,  and  desquamation. 

The  stage  of  incubation  comprises  the  interval  from  the  time  when 
the  contagium  is  taken  into  the  system  until  the  first  symptoms  appear. 
The  prodromal  stage  is  the  period  included  between  the  appearance 
of  the  first  symptoms  and  the  appearance  of  the  eruption.  The  stage 
of  efflorescence  extends  from  the  time  of  the  first  appearance  of  the 
eruption  until  it  fades  and  the  stage  of  desquamation  begins.  As  the 
great  majority  of  cases  run  a  typical  course,  such  a  form  of  the  disease 
will  first  be  described,  always  bearing  in  mind  that  the  many  varia- 
tions and  complications  which  are  later  described  may  alter  the  general 
picture. 

Measles. 
(Rubeola,  Morhilli.) 
Definition. — Measles  is  an  acute  contagious  disease  characterized 
by  a  period  of  incubation,  a  prodromal  stage  with  fever,  coryza,  lacri- 
mation,  cough,  and  Koplik's  spots,  followed  by  a  red,  papular  erup- 
tion and  a  fine  desquamation. 

Etiology. — No  specific  microorganism  has  as  yet  been  discovered. 
The  contagium  is  contained  in  the  nasal,  lacrimal,  and  bronchial  secre- 
tions and,  unlike  scarlet  fever,  to  a  less  extent  in  the  desquamated  epi- 
thelium. It  has  been  transmitted  through  direct  inoculation  of  the 
nasal  secretions  and  blood.  It  is,  therefore,  more  contagious  in  the 
early  stage.  The  contagion  extends  through  the  eruptive  and  desquam- 
ative stages.  It  has  not  the  property  of  clinging  tenaciously  to  such 
15  225 


226  DISEASES  OF  CHILDREN. 

objects  as  clothing,  and  it  is  doubtful  if  it  is  often  carried  by  a  third 
person;  surely  not  as  easily  as  scarlet  fever.  Epidemics  spread  rapidly, 
owing  to  its  transmission  on  short  exposure  and  to  its  highly  contagious 
character  before  the  diagnostic  eruption  appears.  Most  people  have 
the  disease  at  some  time  during  life;  therefore,  adults  are  not  immune 
unless  they  have  already  had  it.  It  is  most  frequent  between  the  first 
and  sixth  years;  rare  before  the  fifth  month,  and  only  5  per  cent,  of 
the  cases  occur  under  one  year.  It  has  occurred  at  birth.  One  attack 
usually  protects  the  individual  from  further  attacks,  but  recurrences 
are  more  common  than  in  any  of  the  other  exanthemata.  It  occurs  in 
all  countries  and  at  all  seasons. 

Pathology. — The  skin  shows  an  infiltration  of  round  cells  which 
surrounds  the  sweat  and  sebacious  glands  as  well  as  the  capillary 
blood-vessels  which  are  found  distended  with  blood.  The  mucous 
membranes  show  inflammatory  changes.  Other  pathological  con- 
ditions, such  as  bronchopneumonia,  are  not  typical  of  measles. 

Incubation. — Eight  to  twelve  days;  usually  ten  days. 

Prodromal  Stage. — Three  to  five  days;  generally  four  days. 
The  onset  is  not  usually  as  abrupt  as  in  scarlet  fever.  The  child 
appears  to  have  a  cold  in  the  head,  has  some  cough,  and  a  temperature 
of  100°  F.  to  104°  F.,  according  to  the  severity  of  the  disease.  There  is 
not  apt  to  be  vomiting,  nor  are  convulsions  common,  although  either 
may  occur.  The  coryza  gradually  increases,  lacrimation  and  the 
nasal  discharge  become  more  profuse,  the  child  grows  sicker,  and 
finally  the  face  assumes  the  puffy  appearance  with  redness  about  the 
nose  and  eyes  commonly  seen  in  a  severe  coryza.  Very  often  a  decep- 
tive fall  in  temperature  with  seeming  improvement  of  the  child's  gen- 
eral condition  takes  place  on  the  second  day,  only  to  be  followed  the 
next  day  by  a  further  rise  of  temperature  and  increased  symptoms, 
which  continue  to  increase  until  the  eruption  is  at  its  height.  There 
may  be  in  some  cases  a  regular  remittent  fever  during  the  three  or 
four  days  of  the  invasion.  Koplik's  spots  which  are  pathognomonic 
of  measles,  and  almost  invariably  present,  are  found  on  the  mucous 
membrane  of  the  cheeks  and  lips  all  through  the  prodromal  stage 
if  inspected  in  strong  sunlight.  The  first  day  there  are  usually  less 
than  six  of  these  rose-red  spots  scattered  over  the  pink  mucous  mem- 
brane, in  the  centre  of  which  are  bluish-white  specks.  Some  are  minute, 
about  one-eighth  of  an  inch  in  diameter.  Soon  they  may  increase  in  num- 
ber until  they  coalesce  and  lose  their  characteristic  appearance  as  the 
exanthem  comes  to  its  height.  Koplik's  spots  are  to  be  differentiated 
from  the  rose  colored  papules  with  superimposed  whitish  vesicles  seen 
on  the  soft  and  hard  palate  in  German   measles,   scarlet  fever,  and 


PLATE  VI 


Measles,  showing  typical  eruption. 


THE  EXANTHEAIATA.  227 

simple  angina,  as  well  as  in  measles.  A  redness  of  the  fauces  and  phar- 
ynx said  to  resemble  the  characteristic  eruption  on  the  skin  is  generally 
seen. 

Eruption. — On  the  third  or  fourth  day  the  exanthem  appears  on 
the  face  in  the  form  of  discrete,  raised,  red,  pin-head-sized  papules. 
The}'  are  sometimes  arranged  in  crescents.  The  eruption  spreads  to 
the  neck,  chest,  back,  and  arms,  and  within  thirty-six  hours  the  whole 
body,  including  the  palms  and  soles,  is  involved.  While  spreading 
thus,  the  papules  on  the  face  are  enlarging  peripherically  until  they 
become  confluent  and  large  areas  are  covered,  with  only  here  and 
there  small  areas  of  intervening  normal  skin.  This  process  takes 
place  also  on  the  rest  of  the  body  in  the  order  in  which  the  eruption 
originally  appeared.  The  whole  face  is  swollen  and  has  a  character- 
istic mottled  appearance  when  the  eruption  is  at  its  height.  The  lids 
are  red  and  edematous,  and  the  conjunctiva  inflamed,  tending  to  keep 
the  eyes  half-closed.  Photophobia  is  pronounced.  This  condition  is 
usually  reached  within  thirty-six  hours  after  the  first  appearance  of  the 
eruption,  and  continues  together  with  the  maximum  temperature, 
coryza  and  cough,  for  one  or  two  days.  During  the  next  two  days 
the  eruption  fades  and  the  temperature  falls,  so  that  within  seven  or 
eight  days  from  the  onset  of  the  first  symptoms,  the  temperature  is 
normal  and  desquamation  is  taking  place. 

Desquamation  begins  in  the  order  in  which  the  eruption  appeared, 
often  beginning  on  the  face  as  the  exanthem  has  reached  its  height 
on  the  limbs.  It  consists  of  fine  flakes  unlike  the  large  lamellae  of 
scarlet  fever.     It  is  completed  in  one  or  two  weeks. 

Variations,  Complications  and  Sequellae. — The  incubation  may 
last  as  long  as  twenty-one  days.  There  may  be  no  symptoms  of  rhini- 
tis or  bronchitis  whatever,  throughout  its  course.  Relapses,  i.e., 
recurrences  of  temperature  and  eruption  are  very  rare,  but  may  occur 
a  few  days  after  the  temperature  has  become  normal. 

Fever. — There  are  afebrile  cases  and  cases  with  hyperpyrexia,  but 
neither  are  common  in  uncomplicated  measles.  The  remission  of  tem- 
perature on  the  second  day  of  the  prodromal  stage  may  not  occur,  but 
the  majority  of  cases  show  it.  A  continued  temperature  after  the 
eruption  subsides,  or  a  persistent  rise  of  temperature  during  the  first 
or  second  week  of  convalescence  always  leads  us  to  suspect  com- 
plications, particularly  bronchopneumonia  or  middle-ear  infection. 

Exanthem. — Occasionally  the  eruption  itself  is  so  atypical  that 
a  diagnosis  can  only  be  made  by  a  general  consideration  of  the  other 
features  of  the  case.  Rarely  it  may  be  erythematous  or  even  vesicu- 
lar in  character,  or  the  papules  may  be  very  large  or  macular  from 


228  DISEASES  OF  CHILDREN. 

the  first.  They  may  vary  from  the  typical  red  color  to  purple  or,  on 
the  other  hand,  they  may  be  very  faint  pink.  There  may  be  minute 
hemorrhagic  spots  about  the  papules  even  in  benign  cases;  or  in  the 
severe  toxic  and  often  quickly  fatal  cases  the  hemorrhagic  areas  are 
extensive  and  simultaneous  hematuria  and  epistaxis  occur.  In 
weakly  children  the  eruption  is  often  very  limited  even  in  severe 
cases.  It  may  vary  in  the  order  of  its  appearance  coming  simultane- 
ously upon  the  face  and  thorax,  or  even  on  the  thorax  or  abdomen 
first.  It  may  subside  entirely  in  twenty-four  hours.  Entire  absence 
of  the  eruption  is  very  rare,  if  it  occurs  at  all. 

Lungs. — Here  we  find  the  most  common  and  the  most  dreaded 
complications  of  measles.  A  mild  bronchitis  with  coarse  mucous  rales 
throughout  the  chest  is  very  common  during  the  early  stage,  and  may 
pass  off  with  the  eruption.  But  often  this  outcome  is  not  so  fortunate, 
for  it  may  continue  into  a  chronic  bronchitis;  or  while  the  disease  is  at 
its  height  the  respirations  may  become  more  rapid,  localized  areas 
of  fine  crepitant  rales  appear,  and  bronchopneumonia  may  develop. 
Its  course  differs  in  no  way  from  the  ordinary  bronchopneumonia, 
being  the  cause  of  death  in  the  great  majority  of  fatal  cases.  It  may 
occur  at  any  time  between  the  beginning  of  the  prodromal  stage  and  the 
completion  of  desquamation.  Lobar  pneumonia  is  seen  less  frequently. 
The  above-mentioned  conditions  of  the  respiratory  tract  make  good 
soil  for  the  growth  of  the  tubercle  bacillus,  so  that  measles  is  one  of  the 
most  frequent  sources  of  pulmonary  tuberculosis  in  childhood.  Un- 
resolved pneumonic  areas  and  continued  cough  and  bronchitis  should 
receive  prompt  attention,  and  the  physician  should  have  this  com- 
plication constantly  in  mind. 

Pertussus  from  previous  exposure  is  considered  a  very  serious 
complication.     Pleurisy  and  empyema  are  less  common  complications. 

Nose,  Pharynx,  and  LARYNX.^The  inflammatory  conditions  here 
may  cause  enough  obstruction  to  lead  to  much  difficulty  in  feeding 
or  in  breathing. 

Spasmodic  croup,  a  pseudomembrane  of  streptococcic  origin  or  a 
double  infection  with  the  diphtheria  bacillus  may  complicate  the 
case.  Diphtheritic  croup  complicating  measles  is  very  fatal  owing  to 
the  rapid  descent  of  the  pseudomembrane  into  the  bronchial  tubes. 
Ulceration  of  the  larynx  may  cause  great  edema  with  extreme  dys- 
pnea or  subsequently  the  scar  may  cause  a  serious  stenosis  of  the 
larynx. 

Ear. — The  external  auditory  canal  may  be  painfully  swollen 
through  extension  from  the  skin.  Otitis  media  is  often  of  a  mild 
grade  when  due  to  infection  through  the  blood,  but  severe  cases  are 


THE  EXANTHEMATA.  229 

due  to  extension  through  the  Eustachian  tube.  Mastoid  disease  has  its 
usual  relation  to  the  otitis  media. 

Eye. — Conjunctivitis  is  of  the  usual  type  in  a  more  or  less  severe 
form.  Keratitis  and  iritis  may  result  and  do  permanent  damage  to 
the  eye.     Any  previous  condition  may  be  rendered  more  active. 

Other  Organs. — The  intestines  are  occasionally  involved,  and 
the  resulting  diarrhea  is  often  severe.  Stomatitis  may  occur  from  the 
same  source.  Cerebrospinal  meningitis  is  occasionally  seen,  particu- 
larly in  the  pneumonic  cases.  The  heart  and  kidneys  are  rarely 
affected  in  uncomplicated  measles,  although  the  kidneys  may  show 
transient  abnormalities  through  the  urine.  Osteomyelitis  and  suppu- 
ration of  the  joints  have  been  seen,  but  are  rare. 

Prognosis. — The  mortality  from  measles  itself  is  not  high,  but 
the  pulmonary  complications  render  it  one  of  the  most  serious  of  chil- 
dren's diseases.  Fatal  cases  almost  invariably  show  bronchopneu- 
monia or  less  frequently  lobar  pneumonia.  The  mortality  averages 
8  to  10  per  cent.,  and  is  greatest  during  the  first  year.  Epidemics 
in  institutions  often  give  a  high  mortality. 

Prophylaxis. — Measles  is  by  no  means  a  mild  disease.  Through 
its  complications  it  is  productive  of  many  deaths.  All  possible  pre- 
cautions should  be  taken  against  the  exposure  of  infants,  especially 
those  under  three  years  of  age.  Isolation  should  be  carried  out  just 
as  soon  as  the  disease  is  suspected  and  should  last  at  least  three 
weeks.  Children  who  have  been  exposed  should  be  kept  segregated 
from  other  children  for  that  period. 

Treatment. — Hygienic  and  hydrotherapeutic  measures  are  of 
greater  importance  than  the  medicinal  treatment.  Select  a  well- 
ventilated  room  that  is  as  far  as  possible  from  direct  communication 
with  the  rest  of  the  house.  The  light  should  be  thoroughly  subdued 
with  dark  shades  until  all  photophobia  is  past.  If  the  fever  is  high 
and  causing  ill  effects,  such  as  delirium,  it  can  be  controlled  by  spong- 
ing with  luke  warm  water  and  by  frequent  drinks  of  cool  water.  If 
a  sedative  seems  necessary,  small  doses  of  phenacetin  will  have  the 
desired  effect  (one  grain  for  a  two-year-old  child  every  two  hours 
for  four  doses).  The  cough  in  the  early  days  of  the  eruption  is  often 
troublesome  and  prevents  sleep.  Small  doses  of  the  bromid  of  sodium 
with  chloral  may  be  given  for  its  conrol.  (Four  grs.  bromid  with  one 
gr.  chloral  every  four  hours  for  a  child  of  five  years  or  codein  phosphate 
YT  of  a  grain  for  one  or  two  doses.)  Ammonium  chlorid  and 
sweetened  cough  mixtures  only  tend  to  produce  an  irritable  stomach 
and  consequent  anorexia.  The  eyes  should  be  bathed  with  4  per  cent, 
boric  acid  solution.     In  some  cases  there  is  considerable  itching  of  the 


230  DISEASES  OF  CHILDREN. 

skin,  and  this  may  be  relieved  by  inunctions  of  5  per  cent,  ichthyol 
and  lanolin.  The  bowels  are  kept  open  preferably  with  small  doses  of 
calomel  or  enemata.  The  ears  should  receive  careful  daily  inspection 
for  any  redness  or  bulging,  and  if  present  an  aurist  may  then  elect  to 
do  incision  and  drainage  of  the  ear  drum.  By  careful  attention  to  the 
eyes,  ears,  and  nasopharyngeal  toilet,  many  of  the  disastrous  com- 
plications of  measles  may  be  avoided.  Bronchopneumonia,  as  a  rule, 
supervenes  more  often  in  those  cases  that  have  been  treated  b}'  sweat- 
ing and  administration  of  hot  drinks,  thus  further  lowering  the  resist- 
ance of  the  child. 

German  Measles. 

(Rdtheln,  Rubeola.) 

Definition. — German  measles  is  a  mild  acute  contagious  disease, 
having  a  period  of  incubation,  a  prodromal  stage  followed  by  a  red 
macular  eruption  and  desquamation.  It  is  attended  by  little  if  any 
systemic  disturbance. 

Etiology. — There  is  no  known  specific  microorganism.  The 
disease  spreads  with  great  rapidity,  the  contagium  taking  place  on 
slight  contact.  It  is  conveyed  by  direct  contact,  and  is  probably  not 
carried  by  a  third  person.  One  attack  usually  protects,  but  it  has 
occurred  in  the  same  individual  a  number  of  times.  Neither  scarlet 
fever  nor  measles  render  immunity,  as  it  seems  to  bear  no  relation  to 
these  diseases. 

Pathology. — There  is  no  specific  pathology. 

Symptomatology. — After  an  incubation  of  between  two  and  three 
weeks,  during  which  there  are  no  symptoms,  a  slight  coryza  or  sore 
throat  develops  with  a  temperature  rarely  over  101°  F.  In  a  great 
many  cases  these  prodromal  symptoms  are  wholly  lacking,  and  in 
about  50  per  cent,  there  is  no  temperature  at  any  time.  There  is 
rarely  more  than  a  slight  indisposition  and  loss  of  appetite.  On  the 
first  or  second  day  the  eruption  appears.  Often  a  premonitory  gen- 
eral blushing  of  the  skin  fading  in  a  few  hours  with  small  discrete 
macules,  deep  pink  in  color,  are  seen  on  the  face. 

These  rapidly  spread  to  the  thorax,  and  thence  within  twenty-four 
hours  to  the  rest  of  the  body,  but  they  are  much  more  numerous  on  the 
face  than  elsewhere.  The  eruption  never  reaches  its  height  in-all  parts 
of  the  body  at  the  same  time,  as  it  begins  to  fade  on  the  face  before  the 
extremities  are  reached.  The  throat  is  reddened.  If  there  has  been 
any  fever  it  disappears  soon  after  the  eruption  comes  out.  In  two  to 
four  days  the  eruption  has  faded,  and  a  slight  brownish  staining  of 


PLATE  VII. 


Rubella  (German  measles). 


THE  EXANTHEMATA.  231 

the  skin,  with  slight  desquamation,  is  at  times  seen.  The  posterior 
and  occipital  lymph  nodes  are  very  constantly  enlarged,  even  before 
the  appearance  of  the  eruption,  and  confirms  the  diagnosis. 

Prognosis. — Recovery  after  a  short  mild  course  is  to  be  expected. 

Treatment. — This  is,  as  a  rule,  mainly  symptomatic.  Beyond  a 
liquid  diet  and  sponging  with  alcohol  very  little  is  required.  In 
severer  cases  the  treatment  given  under  Measles  may  be  appropriately 
followed.  The  children  are  isolated  for  a  period  of  two  or  three  weeks, 
and  their  surroundings  should  be  such  as  described  under  Measles. 

Scarlet  Fever. 
(Scarlatina.) 

Definition. — Scarlet  fever  is  an  acute  infectious,  and  contagious 
disease,  characterized  by  a  sudden  onset,  vomiting,  and  a  generalized 
scarlet  I'ash,  accompanied  by  high  fever. 

Incubation. — Varying  periods  of  incubation  are  recorded.  In 
our  experience  two  to  seven  days  after  exposure  the  symptoms  appear 
The  German  authors  give  an  incubation  period  from  eight  to  eleven 
days. 

Etiology. — The  specific  causative  factor  is  still  unknown.  It 
occurs  more  often  between  the  ages  of  one  to  five.  The  incubation 
period  is  the  least  contagious,  while  the  eruptive  stage  is  the  most 
contagious.  The  stage  of  desquamation  was  formerly  considered  the 
period  of  greatest  danger.  One  attack,  as  a  rule,  protects  the  individual 
from  subsequent  attacks.  The  immediate  neighborhood  of  the  pa- 
tient is  probably  a  contagious  zone.  The  secretions,  as  the  urine  and 
feces,  clothing,  and  desquamated  epithelium  are  the  agents  that  seem 
to  distribute  the  infection.  They  may  retain  this  power  of  infection  • 
for  months  and  even  years. 

Pathology. — The  lesions  found  vary  greatly  with  the  intensity  of 
the  infection,  and  are  due  to  the  action  of  the  scarlatinal  toxin  (strep- 
tococcic) or  to  a  mixed  infection.  The  heart  muscle,  and  the  kid- 
neys show  degenerative  changes.  The  cervical  glands  are  found 
hypertrophied. 

Symptomatology  (Simple  Form). — Vomiting  is  usually  the  first 
symptom.  Convulsions  may  usher  in  the  disease  in  younger  children. 
The  child  has  fever  and  within  twenty-four  hours  the  rash  appears,  first 
upon  the  neck  and  chest.  It  is  bright  in  color,  diffuse,  pin-point,  with 
no  areas  of  healthy  skin  in  between;  it  rapidly  spreads  downward  to 
the  arms,  trunk,  and  legs.  The  face  is  not  as  much  affected  as  the  rest 
of  the  body.     Sometimes  hardly  any  rash  appears  there.     The  rash 


232  DISEASES  OF  CHILDREN. 

is  accompanied  by  a  variable  amount  of  pruritus.  The  tongue  is 
coated  quite  heavily  and  often  has  the  so-called  raspberry  appearance, 
due  to  the  injection  of  the  papillae.  Later  the  tongue  takes  on  a  red 
beefy  appearance  when  the  coating  disappears.  The  fauces  and  tonsils 
are  congested.  The  fever  ranges  from  102°  to  104°  F.,  with  a  rapid 
pulse.  The  glands  in  the  cervical  region  are  tender  and  often  become 
swollen,  especially  in  the  later  stages  of  the  disease.  The  urine  will 
show  traces  of  albumin,  which  is  often  temporary  only.  It  is  apt  to 
be  scanty  and  high  colored. 

The  blood  shows  a  leukocytosis,  while  a  differential  count  may 
assist  in  the  diagnosis  by  showing  an  increase  in  eosinophiles  quite 
early  in  the  disease. 

Desq.amation. — This  begins  with  the  fading  of  the  rash  about  the 
second  or  third  day.  The  skin  appears  in  fine  scales  usually  seen  first 
on  the  face  and  about  the  joints,  then  over  the  body.  On  the  hands 
often  large  sections  of  skin  are  shed.  The  process  lasts  many  days, 
sometimes  weeks,  but  can  generally  be  assisted  by  the  treatment  given 
below. 

Anginal  Form. — The  tonsils  and  retropharynx  are  congested. 
The  tonsils  may  show  exudation  in  their  lacunar  spaces,  and  the  cervical 
lymph-glands  are  much  enlarged.  In  another  form,  a  membrane 
may  be  present  on  both  tonsils  spreading  to  the  adjacent  fauces,  and 
gave  rise  to  the  false  term  of  diphtheritic  scarlet  fever.  It  is  due  to  a 
streptococcic  infection,  and  should  be  regarded  as  the  septic  form  of 
this  disease,  as  in  these  cases  there  is  always  more  or  less  general 
systemic  infection. 

The  fever  in  this  form  is  usually  of  a  remittent  character  and  will 
be  influenced  by  any  complications  that  may  arise.  The  severe 
forms  cause  prostration,  stupor,  or  profound  coma.  The  temperature 
remaining  about  105°  F.  with  rapid  pulse.  The  urine  is  scanty. 
Deglutition  is  extremely  difficult.  There  is  marked  restlessness. 
The  membrane  may  invade  the  nose  or  larynx,  the  lips  are  fissured  and 
the  breath  is  extremely  fetid. 

Routine  examination  of  the  ears  will  often  show  some  degree 
of  involvement  in  more  than  a  fifth  of  the  cases;  if  the  patient  goes  on 
to  recovery  the  lymph-glands  degenerate  with  the  formation  of  ab- 
scesses.    Meningeal  symptoms  may  precede  the  fatal  issue. 

The  mastoid  cells  may  become  diseased  after  convalescence  has 
set  in.  Septic  thrombosis  and  cerebral  abscess  are  fortunately  rarer 
complications.  The  otitis  media  of  scarlet  fever  may  persist,  and  be 
the  cause  of  partial  or  absolute  deafness. 

Kidneys. — Modern    methods    of    urine    examination    will    show 


THE  EXANTHEMATA.  233 

traces  of  albumin  and  a  few  hyalin  casts  even  in  mild  attacks.  This 
should  not  be  regarded  as  a  true  nephritis.  The  septic  form  of 
the  disease  through  the  agency  of  its  toxins  is  more  likely  to  be  com- 
plicated by  a  true  nephritis. 

Puffiness  of  the  eyelids  and  face,  edema  about  the  ankles  spread- 
ing to  the  rest  of  the  body  will  be  the  first  objective  signs.  The  urine 
then  persistently  contains  albumin  and  mixed  casts,  with  a  high  speci- 
fic gravity.  The  nephritis  usually  lasts  through  a  protracted  convales- 
cence or  may  become  chronic.  Uremic  symptoms  begin  with  vomit- 
ing or  convulsions,  sometimes  only  convulsive  movements  are 
observed.     Coma  with  feeble  heart  action  are  symptoms  of  grave  peril. 

The  Rash. — The  development  of  the  rash,  usually  after  twenty- 
four  to  forty-eight  hours,  offers  considerable  information  of  value  in 
differentiating  scarlet  fever  from  the  confusing  erythematous  eruptions. 
The  examiner  should  place  his  patient  in  a  good  white  light.  A  magni- 
fying glass  and  a  glass  slide,  such  as  is  used  for  blood  and  sputum,  will 
be  found  to  be  exceedingly  helpful  in  studying  the  exanthem.  The 
rash  first  makes  its  appearance  on  the  sides  of  the  neck,  upper  part  of 
the  chest  and  face;  thence  spreads  to  the  arms,  upper  part  of  the  back, 
and  finally  involves  the  trunk  and  lower  extremities.  Its  color  is  not 
scarlet,  but  a  dull  red,  almost  a  brownish-red  (Fig.  3,  Plate  IX). 
This  color  varies  proportionately  to  the  fever,  being  more  marked 
usually  in  the  evening.  The  general  characteristics  of  this  rash  about 
to  be  described,  will  always  be  found  present  in  a  true  case  of  scarlet 
fever,  even  though  certain  modifications  or  variations  are  observed. 
Close  inspection  of  the  rash  resolves  it  into  two  factors,  which  are  con- 
stantly present:  1.  An  erythematous  background;  2.  small,  deep 
red,  injected  puncta  (Fig.  5,  Plate  IX).  Sometimes  variations  in 
the  rash  just  described  are  present  which  give  a  diffuse,  a  mottled,  or  a 
speckled  appearance.  These  changes  are  caused  either  by  the  closer 
merging  or  by  the  non-extension  of  these  puncta  with  their  erythe- 
matous areola.  A  normal  or  pale  flesh  tint  is  seen  on  pressure  with  a 
glass  slide  early  in  the  disease,  while  later  there  is  a  dirty,  yellowish- 
red  pigmentation.  Itching  is  quite  a  constant  symptom,  but  is  more 
marked  when  many  groups  of  miliary  vesicles  are  present.  At  the 
height  of  the  eruption,  it  is  often  possible  to  find  small  pin-point, 
conical,  whitish  vesicles,  with  a  serous  content  over  the  chest  and  lower 
abdomen  (Fig.  1,  Plate  IX).  When  they  occur  in  groups  about  the 
axillae  or  in  the  groins,  they  are  quite  confirmatory  from  a  diagnos- 
tic standpoint.  The  harsh,  uneven  feel  which  the  rash  occasionally 
gives  to  the  hand  passed  over  the  skin,  is  due  to  papular  or  even  vesicu- 
lar elevations  occurring  at  the  sites  of  the  hair  follicles      This  papula- 


234  DISEASES  OF  CHILDREN. 

tion  affords  another  valuable  aid,  as  it  does  not  disappear  with  the 
erythematous  rash,  but  the  roughness  of  the  skin  persists  after  it  has 
faded. 

Certain  regional  characteristics  are  present  in  this  exanthem, 
which,  if  appreciated,  tend  to  help  the  puzzled  physician.  The  face, 
for  example,  shows  the  true  rash  only  on  the  temples;  the  cheeks  are 
profusely  red,  but  the  nose,  chin,  and  upper  lip  appear  unduly  pale, 
causing  a  circum-oral  pallid  ring  which  should  be  sought  for  in  sus- 
pected cases,  as  it  is  not  present  in  the  counterfeiting  rashes. 

The  flexor  surfaces  of  the  joints  deserve  careful  scrutiny  and 
special  mention.  These  regions  rarely  exhibit  the  characteristic  rash; 
they  are  apt  to  be  the  site  of  petechial  hemorrhages  or  else  they  have 
a  blotchy  appearance. 

If  the  palms  and  soles  are  examined  with  the  magnifying  glass, 
no  puncta  are  seen,  only  a*  simple  erythematous  blush. 

Desquamation. — In  the  exfoliation  of  scarlet  fever  we  expect  to 
find  it  occurring  in  the  order  of  the  appearance  of  the  exanthem.  At 
first  there  are  observed  fine  discrete  scales  in  the  infraclavicular  and 
episternal  regions  (Fig.  6,  Plate  IX).  These  scales  are  made  up  of 
the  epidermal  covering  of  the  above-described  puncta  and  vesicles. 
When  desquamation  first  occurs  flakes  having  a  perforated  center 
are  cast  off.  This  is  known  as  "pin-holing."  Later,  and  continuing 
for  five  to  seven  weeks,  the  skin  becomes  rougher,  throwing  off  irregu- 
lar rings  of  desquamation  of  varying  extent.  The  large  strips  of 
epithelium  and  casts  of  the  hands  and  feet  which  are  sometimes  shed 
or  torn  away  are  more  often  seen  in  those  subjects  who  have  a  skin  of 
coarse  texture. 

Another  diagnostic  feature  of  this  stage  of  desquamation  is  seen 
in  the  finger-nails.  If  the  pulp  is  pushed  back  from  the  nail,  there 
will  be  seen  just  beneath  its  free  border,  a  scaling  or  cracking  line 
which  extends  up  to  the  fingers.  Four  to  five  weeks  after  the  begin- 
ning of  the  disease,  we  may  find  a  transverse  linear  groove  sometimes 
with  a  corresponding  ridge,  which  shows  itself  on  the  roof  of  the  nail. 
The  thumb-nail  exhibits  this  condition  better  than  the  fingers.  These 
nail  changes  serve  as  corroborative  evidence  in  the  subsequent  diagno- 
sis, and  this  desquamation  may  be  seen  on  the  nails  when  other  evi- 
dences are  not  found  elsewhere.  On  the  other  hand,  it  must  not  be 
forgotten  that  the  desquamation  may  be  so  slight  as  almost  to  escape 
notice.  Unfortunately,  desquamation  alone  is  often  regarded  as 
sufficient  evidence  of  the  disease,  and  a  diagnosis  is  based  thereon. 
In  view  of  the  fact  that  so  many  of  the  erythematous  eruptions  produce 
skin  exfoliation,  we  are  not  justified  in  this  conclusion,  unless  we  have 


PLATE  VIM. 


Rash  of  scarlet  fever. 


THE  EXANTHEMATA.  235 

1,  the  regional  involvement;  2.  the  pin-holing,  and  3.  the  nail  changes, 
plus  other  pertaining  clinical  symptoms. 

The  Tongue. — The  tongue  in  the  first  days  is  usually  thickly 
coated,  and  the  papillae  are  obscured,  but  as  the  tongue  clears  up  at 
the  edges  and  tip,  we  can  observe  the  enlarged  papillsB  (Fig.  4', 
Plate  IX)  which  become  more  and  more  prominent,  and  show  at  their 
best  about  the  fourth  day.  The  lingual  mucous  membrane  now  be- 
gins to  exfoliate;  the  tongue  becomes  red,  dry,  and  glistening.  It  is  in 
the  posteruptive  stage  that  this  feature  is  particularly  of  diagnostic 
importance. 

The  Blood. — The  blood  in  scarlet  fever  has  been  carefully  studied, 
and  may  be  of  service  in  obscure  cases,  as  an  additional  confirmatory 
link.  The  red  blood-cells  are  gradually  diminished  throughout  the 
course.  A  leukocytosis  is  present  a  day  or  two  before  the  appearance 
of  the  rash,  and  the  normal  is  regained  only  in  convalescence.  We 
have  found  this  leukocytosis  to  be  proportionate  to  the  severity  of  the 
angina.  The  polynuclears  are  increased  and  the  mononuclears  de- 
creased, both  relatively  and  absolutely.  To  the  eosinophiles  we  may 
look  for  some  rather  characteristic  variations.  In  the  initial  stages 
they  may  disappear  almost  entirely,  while  in  defervescence,  and  later 
to  the  sixth  or  seventh  week,  8  to  12  per  cent,  may  be  counted. 

Differential  Diagnosis. — The  Erythemata. — Erythematous  erup- 
tions which  may  simulate  the  rash  of  scarlet  fever  are  quite  common; 
and  if  a  careful  examination  and  study  of  the  rash  is  not  made,  weigh- 
ing with  it  all  the  clinical  evidence,  mistakes  are  easily  made.  The 
simple  form  of  erythema  results  from  external  irritants,  while  the 
exanthem  of  angioneurotic  origin  results  either  from  systemic  disturb- 
ance, ingestion  of  certain  drugs,  or  from  specific  poisons.  These  for- 
tunately have  certain  characteristics  which  should  be  borne  in  mind,  for 
while  we  are  not  always  able  to  distinguish  them  one  from  the  other, 
the  differentiation  from  scarlet  may  be  thus  made  possible. 

One  of  the  striking  features  is  the  tendency  to  recurrence,  and 
undoubtedly  many  of  the  so-called  second  and  third  attacks  of  scar- 
latina have  been  in  this  class.  In  a  general  way  these  dermatoses 
are  distinguished  by  the  following  peculiarities:  They  may  appear 
in  any  region  of  the  body — at  one  time  there  may  be  present  in  the 
erythema  elements  of  the  various  exanthemata.  Their  type  may 
rapidly  change  so  that  they  may  be  scarlatiniform  one  day  and  mor- 
billiform the  next.  The  puncta  seen  in  the  scarlet  fever  exanthem 
are  absent.  Desquamation  is  coarse  and  flaky,  and  recurrences  are 
frequent. 

Erythema  Scarlatiniforme. — This  is  a  non-contagious  derma- 


236  DISEASES  OF  CHILDREN. 

titis,  simulating  scarlet  fever  in  its  cutaneous  manifestations.  It  is 
liable  to  occur  secondarily  to  other  infectious  diseases  and  to  medici- 
nal and  food  intoxication.  As  it  is  important  to  differentiate  the 
disease  from  scarlatina,  its  distinguishing  features  will  therefore  be 
given. 

This  erythema  spreads  very  rapidly,  sometimes  reaching  its 
height  in  a  few  hours.  Patches  of  erythema  may  alone  be  present. 
Under  the  glass  there  is  no  uniform  redness.  The  face  is  rarely  in- 
volved and  the  tongue  shows  no  ''raspberry"  appearance.  The  fau- 
ces may  be  red  but  are  not  swollen.  Desquamation  takes  place  at  an 
early  date  after  the  erythema,  sometimes  on  the  second  day;  it  is  a 
quick  process  and  the  scales  are  large,  abundant,  and  furfuraceous. 
The  course  is  brief,  and  there  are  no  complications  or  sequelae.  Such  a 
clinical  picture,  especially  in  a  child  who  has  given  a  history  of  previous 
similar  attacks,  should  exclude  scarlatina.  A  scarlatinoid  erythema 
may  follow  the  use  of  such  drugs  as  belladonna,  quinin,  chloral,  chlore- 
ton,  salicylic  acid,  antipyrin,  digitalis,  opium  or  veronal,  especially 
in  those  patients  having  a  drug  idiosyncrasy.  These  eruptions 
almost  invariably  follow  very  quickly  after  the  ingestion  of  the  drug. 
We  have  seen  it  occur  within  an  hour  after  a  dose  of  antipyrin.  The 
close  relationship  to  the  drug  taking,  is  a  diagnostic  feature  of  consider- 
able value.  Belladonna  rashes  are  perhaps  most  often  seen.  This 
eruption  is  usually  confined  to  the  face,  neck,  and  chest,  and  is  only 
rarely  generalized.  It  fades  quickly  and  is  rarely  followed  by  any  des- 
quamation. The  absence  of  fever,  the  dilated  pupils,  the  evanescent 
rash  and  the  history  should  cause  no  confusion. 

It  is  well  to  recollect  that  drug  rashes  in  general,  and  in  contrast 
to  scarlet  fever,  appear  for  the  most  part  on  the  extensor  surfaces 
of  the  extremities,  and  if  they  be  present  on  the  face,  then  the  circum- 
oral  I'ing  is  not  observed.  Moreover,  they  are  not  associated  with 
fever,  angina,  or  adenitis.  If  any  doubt  still  exists,  the  repetition  of 
the  dose  of  medication  under  suspicion  should  be  given  to  reproduce 
the  erythema. 

Acute  Exfoliative  Dermatitis. — Another  disease  which  may 
raise  a  veritable  doubt  in  the  stage  of  efflorescence  or  in  the  desquama- 
tive period  is  acute  exfoliative  dermatitis.  It  differs  in  that  the  consti- 
tutional symptoms  are  more  pronounced  than  in  scarlatinoid  ery- 
thema, while  the  eruption  appears  as  a  general  hyperemia  very,  soon 
covering  the  entire  body.  The  exfoliation  follows  in  a  day  or  two,  and 
is  general  in  character  and  intensely  profuse;  large  papery  strips  being 
cast  off  (Fig.  8,  Piute  IX).  The  nails  and  hair  may  drop  out  before 
the  process  is  complete. 


PLATE   IX, 


The  diflferential  diagnosis  of  scarlet  fever  and  the  Scarlatiniform  eruptions. 
1.  Scarlet  fever  rash  showing  sudaminal  vesicles.  2.  The  fading  scarlatina 
eruption.  3.  Scarlatina  eruption,  early  stage.  4.  Typical  scarlet  fever  tongue. 
5.  The  scarlet  fever  rash,  magnified.  6.  Scarlet  fever  desquamation.  7.  The 
scarlatinal  form  of  rubella.  8.  Acute  exfoliative  dermatitis.  9.  Erythema  in- 
fectiosa.     (Pisek's  original  plate;  courtesy  Archives  of  Diagnosis.) 


THE  EXANTHEMATA.  '237 

Another  disease  which  necessitates  correct  interpretation  is  the 
scarlatiniform  variety  of  rubella;  fortunately,  this  is  not  a  common  type 
(Fig.  7,  Plate  IX).  Close  inspection  of  the  rash  will  disclose  morbilli- 
form characteristics.  The  mild  constitutional  symptoms  and  the 
enlarged  postcervical  glands  of  rubella  will  define  it. 

Serum  Rashes. — The  use  of  antitoxic  serum  may  be  productive 
of  a  scarlatinoid  rash  that  is  very  puzzling.  This  is  especially  true 
when  antidiphtheritic  serum  has  been  injected.  The  angina  of  the 
diphtheria  is  already  present  and  cannot  assist  us,  while  fever  and 
malaise  supervene.  We  must  then  depend  upon  the  following  facts: 
That  the  rash  frequently  spreads  from  the  site  of  the  injection;  that 
these  rashes  are  often  polymorphous  in  character  and  fleeting  in 
duration.  They  appear  on  the  third  or  fourth  day,  the  eruption  occurs 
usually  in  patches  and  only  rarely  appears  on  the  face.  A  well-marked 
enlargement  of  the  superficial  lymph-glands  in  the  inguinal,  axillary, 
and  epitrochlear  regions  will  also  help  to  distinguish  this  rash  from 
scarlatina. 

Open  wounds  and  especially  burns  are  liable  to  direct  inoculation. 
Many  of  the  so-called  cases  of  "surgical  scarlet"  of  the  older  writers 
were  probably  scarlatinoid  erythemas  or  what  we  now  recognize  as 
septic  rashes.  For  our  guidance  in  differentiation  the  wound  is  of 
considerable  help;  an  erstwhile  healthy  wound  may  begin  to  look  un- 
healthy, and  an  exudate  may  form  upon  it.  The  rash  is  very  likely  to 
first  appear  at  or  near  the  wound.  The  nearest  lymphatic  nodes 
will  be  found  tender  and  enlarged.  Vomiting  may  occur,  but  sore 
throat  is  rarely  complained  of.  There  are  no  characteristic  changes 
in  the  desquamation. 

The  septic  rashes  which  were  referred  to  above,  occur  more  often 
in  early  life,  and  either  precede  or  accompany  a  definite  septicopyemia. 
Occasionally  they  may  indeed  be  the  first  to  call  attention  to  the  true 
condition  of  the  patient.  When  the  rash  is  small  and  macular,  it  may 
resemble  scarlet  fever.  Its  spotted  character  and  the  large  macules 
which  are  seen  on  the  extensor  surfaces  of  the  extremities  with  ab- 
sence of  puncta  fix  the  diagnosis  (Fig.  9,  Plate  IX).  A  high  leuko- 
cytosis would  be  confirmatory.  From  erysipelas  scarlatina  can  be 
distinguished  by  the  shining,  glazed  appearance  and  characteristic 
spreading. 

The  Fourth  or  Duke's  disease  is  of  interest  in  this  connection 
because  of  its  confusion  with  scarlet  fever,  provided  we  accept  the 
dictum  that  attacks  of  the  Fourth  disease  do  not  protect  the  individual 
against  scarlet  fever  and  measles.  The  disease  is  described  as  dififer- 
ing  from  scarlet  fever  in  its  longer  incubation  period,   absence  of 


238  DISEASES  OF  CHILDREN. 

prodromal  symptoms,  such  as  vomiting,  high  pulse  rate,  and  severe 
angina.  The  rash  itself  shows  but  little  difference  except  that  it  usu- 
ally begins  on  the  face  and  is  not  extensive.  The  desquamation,  how- 
ever, is  profuse  and  out  of  all  proportion  to  the  exanthem.  Renal  com- 
plications do  not  occur. 

As  the  practitioner  is  often  called  upon  to  offer  a  diagnosis  at 
different  stages  of  the  disease,  the  distinctly  helpful  phenomena  to  be 
observed  at  various  stages  in  scarlatina  will  be  given. 

Preeruptive  Stage. — Here  the  diagnosis  is  only  rarely  possible 
and  then  it  can  be  made  only  in  the  presence  of  an  epidemic  and  a 
history  of  contagion.  The  sudden  invasion  with  an  angina,  bright 
red  puncta  seen  in  the  roof  of  the  mouth,  and  initial  vomiting  without 
satisfactory  cause,  may  be  symptoms  anteceding  the  eruption. 

Eruptive  Stage. — The  diagnosis  is  at  this  period  rarely  obscure. 
The  vomiting,  high  pulse  rate,  characteristic  punctate  rash,  congested 
fauces  and  evidences  of  the  "raspberry"  tongue  are  usually  conclusive, 

Predesquamative  Stage. — The  rash  has  faded  or  disappeared, 
and  desquamation  has  not  yet  begun.  Here  the  distinctively  glazed, 
papillated  tongue  and  the  injected  fauces  are  seen.  The  enlarged 
lymph  nodes  beneath  the  maxilla  are  tender  to  the  touch.  The  skin 
looks  dirty  yellow  under  a  glass  slide,  and  has  a  distinctly  dry  and 
uneven  feel.     Sudamina  or  miliary  vesicles  may  be  present  in  groups. 

Desquamative  Stage. — When  the  disease  is  seen  late,  exfoliation 
beginning  on  the  face  may  be  found  on  the  fourth  to  the  sixth  day 
of  the  disease,  and  on  the  neck  and  chest  about  the  twelfth  to  the 
fourteenth  day.  On  the  palms  of  the  hand  and  soles  of  the  feet  it  per- 
sists sometimes  for  weeks;  this  possibly  serving  to  differentiate  it 
from  the  scarlatiniform  erythemas.  "Pin-hole"  scaling  on  the  body 
and  the  lines  on  and  beneath  the  finger-nails  strengthen  the  diagnosis. 
It  is  not  uncommon  to  find  still  further  corroborative  evidence  at  this 
stage  in  complications  of  the  kidneys,  joints,  in  the  ear  or  in  suppur- 
ating cervical  glands. 

Prognosis. — In  the  mild  cases  this  is  extremely  good.  The  septic 
cases  in  the  epidemics  raise  the  mortality.  In  this  country  the 
mortality  in  several  epidemics  averaged  3  per  cent.  Nephritis  is  the 
most  common  complication  and  often  a  fatal  one  through  uremia. 
The  chronic  form  reacts  badly  to  treatment  and  often  ends  in  death. 
Otitis  and  its  complications  may  result  in  deaf-mutism  or  have  a 
fatal  issue  through  the  involvement  of  the  brain  or  sinuses.  The  in- 
volvement of  the  serous  membranes  of  the  heart  or  joints  tends  to  a 
grave  prognosis.     The  older  the  patient  the  better  the  prognosis. 


THE  EXANTHEMATA.  239 

Treatment.  Prophylactic. — The  routine  examination  of  school 
children  which  is  now  practised  in  a  number  of  the  largest  cities,  will 
notably  tend  to  diminish  the  number  of  scarlet  fever  cases  and  pre- 
vent epidemics.  Isolation  should  be  insisted  upon,  and  be  carefully 
carried  out  even  in  mild  or  suspected  cases.  Children  or  even  adults 
who  have  been  subject  to  pharyngitis  or  tonsillitis  are  more  likely  to 
take  or  spread  the  infection.  Air  and  sunlight  should  be  regarded  as 
the  best  disinfectants. 

Children  from  whom  enlarged  tonsils  and  adenoids  have  been 
previously  removed  are  less  liable  to  such  complications  as  otitis  and 
sinusitis. 

Sick-room  and  Quarantine. — A  quiet  sunny  room  that  can  best  be 
used  for  purposes  of  isolation  should  be  selected.  An  open  fire-place 
is  preferable  to  any  other  form  of  heating. 

All  unnecessary  furniture  should  be  removed,  a  gown  or  sheet 
and  a  bowl  of  bichlorid  of  mercury(l-lOOO)  should  be  placed  in  readi- 
ness in  an  empty  closet  outside  of  the  room  for  the  use  of  the  doctor. 

During  convalescence  toys  of  little  value,  that  can  be  burned, 
should  be  provided  so  that  the  period  of  quarantine  which  is  usually 
six  weeks  may  not  be  too  irksome  for  the  child. 

Disinfection  can  be  carried  out  as  described  on  page  312  when 
the  patient  is  ready  to  be  discharged. 

Routine  Measures. — All  cases  of  scarlet  fever,  whether  mild  or 
severe,  should  be  regarded  as  dangerous,  as  the  complications  and  se- 
quelae may  permanently  inj  ure  the  patient.  S killed  nursing  will  do  more 
to  promote  the  comfort,  progress,  and  the  prevention  of  complications 
than  remedial  measures.  If  circumstances  will  not  permit  of  a 
trained  nurse,  some  one  member  of  the  household  should  be  put  in 
charge  and  given  careful  instructions  as  to  the  quarantine  regulations 
and  written  orders  for  the  patient. 

The  diet  should  consist  wholly  of  milk  in  the  first  few  days  of  the 
illness,  later  for  the  sake  of  variety  fruit  juices,  whey,  buttermilk,  or 
matzoon  may  be  added  or  substituted. 

When  convalescence  is  established,  gruels,  crackers,  well-toasted 
bread,  and  apple  sauce  may  be  added  to  the  dietary.  Vegetables 
and  eggs  are  allowed  in  the  fourth  or  fifth  week  if  there  is  no  fever  or 
other  contraindication.  Water  should  be  offered  often  and  freely 
throughout  the  illness. 

The  skin  should  be  annointed  with  a  5  per  cent,  boric  acid  oint- 
ment or  with  liquid  albolin  daily  as  soon  as  desquamation  is  estab- 
lished. If  the  pruritis  is  troublesome  a  1  or  2  per  cent,  carbolic  acid 
ointment  will  be  effective  in  its  control. 


240  DISEASES  OF  CHILDREN. 

The  nasopharyngeal  toilet  should  be  made  daily  with  a  mild  alka- 
Une  antiseptic  or  a  normal  saUne  solution.  The  method  employed  will 
depend  upon  the  age  of  the  child.  Those  who  are  old  enough  and 
willing  may  gargle.  A  spray  or  irrigation  is  necessary  for  the  ob- 
streperous or  septic  cases.  The  solution  may  be  instilled  with  a  medi- 
cine dropper  into  the  nares  of  infants. 

The  Urine. — A  specimen  should  be  obtained  for  examination 
(see  Methods,  page  445)  three  times  a  week.  If  this  is  done  the  com- 
plicating nephritis  will  be  detected  ear  y  and  proper  measures  can  be 
taken  at  once. 

Symptomatic  Treatment. — The  fever,  if  high,  above  104°  F,,  can  be 
controlled  by  sponging  with  water  85°  to  90°  F.  every  two  or  three 
hours.  Cool  packs  are  rarely  necessary  except  in  those  cases  in  which 
there  is  considerable  restlessness  and  delirium.  The  child  may  then 
be  wrapped  in  a  sheet  as  described  on  page  68  and  left  in  this  for  a 
few  hours  if  sleep  is  produced. 

Heart. — Persistent  high  fever,  especially  in  the  septic  cases,  may 
weaken  the  action  of  the  heart  so  that  the  pulse  becomes  soft  and 
somewhat  irregular.  The  first  sound  is  not  distinct  and  the  pulse  rate 
becomes  high.  Stimulation  with  strychnia  alternating  with  the  tinc- 
ture of  strophanthus  is  now  indicated.  Alcohol  in  the  form  of  sherry 
wine  (vini  xerici)  may  be  substituted  profitably  in  the  septic  cases. 
One  to  two  ounces  may  be  given  diluted  in  water  or  milk  during 
the  twenty- four  hours  to  a  five-year-old  child.  Normal  salt  solution, 
two  to  three  ounces,  given  by  hypodermoclysis  may  tide  over  a  criti- 
cal period. 

The  bowels  are  kept  open  preferably  with  the  effervescent  citrate 
of  magnesia.  Constipation  which  is  so  often  present  on  a  strictly 
milk  diet  will  not  be  so  troublesome  if  the  dietary  is  varied  as  out- 
lined above.  The  milk  of  magnesia  may  be  added  to  the  bottle  in 
infants. 

Complications  and  Sequelae. — The  cervical  adenitis  which  so 
often  occurs  requires  the  use  of  ice-bags  in  the  early  stages.  Ichthyol 
ointment  20  to  30  per  cent,  in  lanolin  is  applied  daily  when  the  acute 
symptoms  have  subsided.  The  abscess  must  be  incised  and  drained 
if  fluctuation  denoting  suppuration  is  detected. 

Nephritis  will  necessitate  the  continuance  of  a  liquid  diet,  alkaline 
diuretics,  and  in  the  graver  cases  high  colonic  irrigations  of  saline 
solution  twice  a  day  until  the  normal  amount  of  urine  is  reached. 

Otitis. — The  ear  drums  should  be  examined  ever}^  other  day  as  a 
routine  measure,  and  any  redness  and  bulging  should  receive  prompt 
treatment    by  incision  and    drainage  as  outlined    on  page  567.     If 


THE  EXANTHEMATA. 


241 


this  is  done;  chronic  otitis  and  mastoid  infections  with  their  sequelae 
may  be  avoided. 

Arthritis  occasionally  occurs  as  a  complication  which  prolongs  the 
convalescence,  and  if  neglected  may  cause  joint  deformities  (Fig.  68). 
Aluminum  acetate  solution,  N.F.,  applied  as  a  wet  dressing,  with  small 
doses  of  phenacetin,  may  arrest  the  inflammatian  and  control  the 
pain.  If  suppuration  takes  place  surgical  intervention  is  necessary. 
At  the  Willard  Parker  Hospital  good  results  have  sometimes  been 
obtained  by  immobilizing  the  inflamed  joints  with  plaster  of  Paris. 


Fig.  68. — Arthritis,  following  scarlet-fever,  in  left  hip-joint. 


The  Serum  Treatment. — Except  in  those  cases  which  by  culture 
give  evidences  of  an  added  Klebs-Loeffler  infection,  serum  therapy  as 
thus  far  elaborated  is  without  value.  Diphtheria  antitoxin  then 
should  be  administered  in  those  cases  only  in  which  a  true  diphtheria 
is  present. 

Small -pox. 

{Variola). 
Definition. — Small-pox  is  an  acute  contagious  disease  characterized 
by  a  period  of  incubation,  a  prodromal  stage  with  intense  constitu- 
tional symptoms,  followed  b}^  a  progressive  eruption  of  macules,  pap- 
ules, vesicles,  pustules,  and  cicatrices. 
16 


242  DISEASES  OF  CHILDREN. 

Etiology. — Specific. — Councilman  in  1903  discovered  a  protozoan 
in  the  skin  of  small-pox  patients  The  relation  of  these  parasites  to 
the  skin  lesions  is  of  such  a  definite  and  intimate  character  as  to  lead 
to  the  conclusion  that  they  are  the  cause  of  the  disease.  They  have  a 
double  life  cycle,  intracellular  and  intranuclear,  which  they  undergo 
in  the  epithelial  cells.  In  the  first  cycle  they  are  small  homogeneous 
bodies  found  in  vacuoles  in  the  cells  of  the  lower  layer  of  epithelium, 
and  develop  there  into  large  ameboid  multi-chambered  organisms, 
destroying  the  epithelial  cell  and  by  segmentation  breaking  up  to 
form  the  protozoa  of  the  second  cycle.  These  invade  the  nuclei  of 
other  epithelial  cells  and  continue  their  growth  until  the  cell  is  de 
stroyed.  The  parasite  has  not  been  found  free  in  the  vesicle  contents, 
nor  anywhere,  as  yet,  except  in  prepared  sections  of  the  skin. 

Non-specific. — The  contagium  exists  in  the  secretions  and  excre- 
tions, in  the  skin  lesions,  and  in  the  dried  scales  and  crusts  that  come 
from  them.  It  clings  to  everything  with  which  it  comes  in  contact, 
and  may  therefore  be  transmitted  by  a  third  person;  all  public  places 
are  thus  dangerous  for  an  unvaccinated  individual  during  an  epidemic. 
It  is  probably  contagious  during  the  prodromal  stage  as  well  as  through- 
out the  course  of  the  eruption  an  desiccation.  A  very  virulent  case  of 
variola  may  be  contracted  from  the  mildest  varioloid.  Vaccination 
protects  for  a  variable  time  (six  years  to  a  lifetime)  in  different  individ- 
uals, and  always  lessens  the  danger  and  severity  of  an  attack.  One 
attack  protects  for  life. 

Pathology. — The  papule  is  seen  to  be  a  focus  of  coagulation  ne- 
crosis in  the  rete  mucosa,  surrounded  by  an  area  of  active  inflamma- 
tion. The  vesicle  is  made  up  of  numerous  recticulse  and  spaces  which 
contain  serum,  leukocytes,  and  fibrin.  When  the  pustule  involves  the 
true  skin  a  permanent  scar  results. 

Incubation. — Twelve  to  fifteen  days. 

Prodromal  Stage. — Three  or  four  days. 

Symptomatology.  Description  of  Prodromal  Stage. — This  is 
ushered  in  with  convulsions,  vomiting  or  a  chill,  and  in  older  children 
severe  frontal  headache  and  backache  are  complained  of.  The  tem- 
perature quickly  rises  from  103°  F.  often  to  106°  F.  The  pulse  becomes 
rapid  and  full,  and  within  twenty-four  hours  there  may  be  delirium 
and  marked  restlessness.  This  condition  continues  with  no  di- 
agnostic signs  on  the  skin  usually  for  four  days,  when  the  eruption 
appears.  Simultaneously  there  is  a  fall  of  temperature  even  to 
normal  in  the  less  severe  cases,  and  marked  improvement  in  the 
general  symptoms. 

The  Exanthem. — At  first  the  exanthem  is  in  the  form  of  small 


Differential  diagnosis  of  variola  and  varicella,     (a)  variola;  (b)  varicella. 


THE  EXANTHEMATA.  243 

raised  red  papules,  most  commonly  developing  on  the  forehead, 
particularly  at  the  junction  with  the  hair,  and  on  the  wrists.  They 
rapidly  extend  to  the  rest  of  the  face  and  to  the  extremities,  in- 
cluding the  palms  and  soles,  and  in  !ess  numbers  to  the  trunk. 
They  all  come  out  in  one  crop  within  twenty-four  hours.  They 
feel  hard  and  have  the  so-called  "shotty"  touch,  because  they 
extend  deeper  into  the  skin  than  other  papules,  as,  for  instance,  those 
of  chicken-pox.  These  same  red  papules  are  to  be  seen  on  the  hard 
and  soft  palate  and  pharynx  causing  an  accompanying  sore  throat. 
In  two  days,  sometimes  less,  the  papules  on  the  skin  become  vesicular 
with  a  slight  depression  in  the  center  of  each  vesicle,  and  if  pricked 
with  a  needle  they  do  not  collapse  because  they  are  divided  into  many 
parts  by  a  reticular  construction.  They  still  have  an  indurated  red- 
dened base.  On  the  eighth  day  of  the  disease,  four  days  after  their 
first  appearance,  the  vesicles  become  full  and  rounded  and  the  serum 
in  them  changes  to  pus.  The  skin  becomes  tense  and  swollen,  and 
the  individual  lesions  enlarge,  so  that  in  the  severe  cases  (confluent 
form)  they  coalesce  and  the  face  appears  much  swollen  and  changed 
beyond  recognition.  This  is  accompanied  by  a  second  rise  of  tem- 
perature (secondary  fever),  and  a  return  of  the  constitutional  symp- 
toms with  redoubled  vigor.  The  delirium  returns,  the  pulse  grows 
weaker,  and  the  patient  shows  every  sign  of  a  severe  intoxication.  In 
the  fatal  cases  this  may  go  on  for  two  or  three  days  with  increased 
severity  until  death  results.  But  in  the  milder  cases,  within  twenty- 
four  to  thirty-six  hours  after  maturation  takes  place,  the  pustules 
break  and  the  pus  exudes,  and  on  the  tenth  or  eleventh  day  the  tem- 
perature begins  to  fall  by  lysis.  The  pustules  rapidly  dry  with  the 
formation  of  crusts,  and  usually  during  the  third  week  the  temperature 
becomes  normal  and  the  desiccated  pustules  alone  remain.  These 
may  adhere  for  a  week  or  longer  until  at  last  they  fall  off  and  leave  the 
scar  or  pit  which  may,  especially  in  the  confluent  form,  be  carried 
throughout  life.  A  leukocytosis  occurs  in  the  pustular  stage,  but  at 
no  other  time  unless  there  is  some  complication  to  cause  it. 

Variat  ons,  Complications,  and  Sequelae. — There  are  really  four 
forms  of  small-pox,  differing  chiefly  as  to  their  severity;  varioloid, 
discrete,  confluent,  and  hemorrhagic  small-pox.  Varioloid  is  a  pox 
modified  by  a  previous  vaccination,  and  does  not  often  occur  in  chil- 
dren, since  a  child  that  has  been  successfully  vaccinated  is  generally 
immune  until  after  puberty.  The  mild  discrete  form  is  also  unusual, 
because  in  unvaccinated  children  small-pox  is  apt  to  run  a  very  severe 
course.  These  two  forms  are  mild  and  dififer  only  in  degree.  The 
symptoms  are  all  milder  than  in  the  other  two  forms,  although  the 


244  DISEASES  OF  CHILDREN. 

initial  temperature  may  be  high.  The  papules  are  fewer  in  number, 
particularly  on  the  face,  and  do  not  coalesce.  The  disfiguration  is 
less.  There  is  less  secondary  fever  from  suppuration  (in  varioloid 
often  more)  and  convalescence  is  there  ore  much  more  rapid.  In  the 
confluent  form  the  eruption  is  apt  to  appear  earlier,  about  the  third 
day,  with  a  lesser  fall  of  temperature  upon  the  advent  of  the  eruption. 
There  is  more  swelling  and  distortion  of  the  eatures  during  the  suppu- 
rating and  coalesc  ng  stage  and  more  pain.  Delirium,  ceaseless,  rest- 
less movements,  and  other  nervous  manifestations  are  prominent  in 
children.  Diarrhea  is  also  peculiar  in  children.  The  larynx  and 
pharynx  may  be  greatly  swollen.  Edema  at  times  being  the  cause 
of  death  through  suffocation.  The  cervical  glands  are  much  swollen 
and  may  suppurate.  Hemorrhagic  small-pox  may  show  itself  either 
before  the  real  eruption  appears  or  at  the  time  of  suppuration  and 
secondary  fever  the  earlier  the  hemorrhage,  the  greater  the  danger. 
At  first  there  are  small  punctiform  hemorrhages.  They  rapidly  in- 
crease in  size,  and  soon  hemorrhages  appear  from  the  mucous  mem- 
branes, hematemesis,  hemoptysis,  epistaxis,  and  hematuria  develop. 
Large  conjunctival  hemorrhages  with  deeply  sunken  cornea  complete 
the  picture.  The  pulse  is  rapid  and  the  respirations  frequent.  On 
the  other  hand,  hemorrhage  into  the  vesicles  themselves  with  abortion 
of  the  rash  and  speedy  recovery  even  in  cases  that  were  previously  con- 
sidered severe,  have  been  noted. 

Other  complications  are  fatal;  edema  or  necrosis  of  the  larynx. 
Bronchopneumonia  is  common.  Heart  and  kidney  complications 
are  rare.  Arthritis  going  on  to  suppuration,  and  acute  necrosis  of 
the  bones  have  occurred.  The  eye  may  be  permanently  injured  by 
inflammatory  changes.  Otitis  media  may  complicate.  Boils,  acne, 
and  ecthyma  are  apt  to  be  troublesome  sequelae. 

Prognosis. — The  matter  of  previous  successful  vaccination  is  the 
most  important  item  in  the  course  and  termination  of  small-pox. 

In  one  large  epidemic  the  mortality  of  the  unvaccinated  was  54 
per  cent.,  while  that  of  the  vaccinated  was  ^  of  1  per  cent.  In  chil- 
dren it  is  particularly  fatal.  Of  3,164  deaths  in  the  great  Montreal 
epidemic,  85  per  cent,  of  these  were  in  children  under  ten  years.  The 
younger  the  child  the  more  serious  the  course,  and  the  more  fatal  the 
outcome.  The  hemorrhagic  form  is  almost  invariably  fatal.  The  more 
numerous  the  lesions  on  the  face  the  more  grave  is  the  prognosis,  as  is 
seen  in  the  high  mortality  of  the  confluent  form.  High  fever,  delirium, 
continued,  convulsions  and  other  nervous  symptoms  are  particularly 
dangerous.  Laryngeal  and  pulmonary  complications  are  very  fatal  in 
children. 


THE  EXANTHEMATA.  245 

Prophylaxis. — Vaccination  is  the  measure  which,  if  thoroughly 
carried  out,  would  eradicate  this  disease. 

The  strictest  quarantine  regulations  must  be  enforced  even  in 
suspected  cases;  all  individuals  exposed  are  to  be  immediately  vacci- 
nated. The  demands  of  school  boards  that  all  children  be  frequently 
vaccmated  has  been  followed  by  the  most  satisfactory  results. 

Treatment. — If  the  patient  has  not  been  vaccinated,  and  is  in  the 
incubat  on  stage,  the  ravages  of  the  disease  may  be  prevented  and 
only  a  mild  course  observed,  if  he  be  immediately  vaccinated.  The 
high  fever  is  controlled  by  cold  sponging  and  the  use  of  the  ice-bag 
under  skilled  supervision.  The  racking  pains  are  best  controlled  in 
children  by  Dover's  powders.  Water  is  freely  demanded  and  should 
be  freely  given.  Convulsions  and  other  nervous  phenomena  may  be 
prevented  and  relieved  by  insisting  upon  a  cool  temperature  in  the 
room;  preferably  at  65°  to  70°  F.  The  diet  should  be  liquid  during 
the  febrile  period.  A  4  per  cent,  solution  of  boracic  acid  should  be 
used  for  the  eyes,  mouth,  and  nose.  A  2  to  5  per  cent,  ichthyol 
ointment,  or  a  wet  dressing  of  the  liq.  alumini  acetatis  (N.F.)  will 
very  effectively  control  the  itching  in  the  eruptive  stage.  A  great 
deal  may  be  done  for  the  patient  during  the  stage  of  suppuration. 
Welch,  who  has  had  a  large  experience,  recommends  the  application  of 
a  mixture  of  olive  oil  and  lime-water  ^  oz.  each  with  carbolic  acid  ten 
to  fifteen  drops.  Elbow  sleeves  will  effectively  prevent  the  child  from 
scratching  and  thus  causing  pitting  and  disfigurement.  Martin  states 
that  he  can  prevent  pitting  by  treating  each  pustule  by  incision  and 
drainage.  The  patient's  strength  is  to  be  carefully  watched  and  strych- 
nin prescribed  at  the  first  signs  of  a  weakening  heart.  In  the  con- 
valescent stage,  forced  feeding  will  serve  as  the  best  tonic  treatment. 

Vaccination. 

Definition. — Vaccination  is  the  innoculation  of  an  individual  with 
the  virus  taken  from  the  vesicle  of  a  cow  that  has  vaccinia  or  cow-pox. 

Etiology. — It  is  now  known  that  vaccinia  is  caused  by  a  proto- 
zoan which  resembles  that  of  small-pox,  but  which  differs  from  the 
latter  in  that  it  has  only  one  life  cycle,  the  intracellular  form  described 
under  the  etiology  of  Small-pox. 

Value  of  Vaccination. — In  the  immense  majority  of  cases  vaccina- 
tion renders  the  individual  immune  from  small-pox  for  many  years. 
Before  it  was  generally  practised  terribly  fatal  epidemics  swept  over 
different  parts  of  the  world,  carrying  away  enormous  numbers  of 
victims.     Rotch  states  that  in  the  last  fifteen  years  no  deaths  from 


246  DISEASES  OF  CHILDREN. 

small-pox  have  occured  in  Boston  in  children  who  had  been  vaccinated 
under  five  years  of  age,  and  at  the  same  time  the  mortality  in  the  un- 
vaccinated  was  75  per  cent.  Where  small-pox  is  acquired  after  suc- 
cessful vaccination,  even  years  after,  it  is  the  mild  form,  called  varioloid. 

When  to  Vaccinate. — Every  infant  should  be  vaccinated  prefer- 
ably between  the  fourth  and  sixth  months  of  life,  before  teething  has 
begun  and  before  the  child  can  disturb  the  dressing.  An  acute  or  a 
severe  chronic  disease  is  a  contraindication  except  in  an  emergency. 
Revaccination  is  advisable  at  puberty,  and  at  any  other  time  when 
the  child  has  been  exposed  to  small-pox  or  during  a  general  epidemic. 
If  an  unprotected  child  is  vaccinated  within  two  days  after  exposure 
to  small-pox,  it  will  probably  not  contract  that  disease,  and  if  vacci- 
nated within  five  days  thereafter  the  small-pox  will  be  modified,  and 
it  will  convert  a  possibly  severe  case  into  a  mild  one. 

Method  of  Vaccination. — Only  sealed  tubes  or  quills  should  be 
used.  Boys  are  vaccinated  on  the  left  arm  at  the  insertion  of  the 
deltoid,  girls  on  the  thigh  or  calf.  The  skin  is  carefully  cleaned  with 
soap  and  water  and  a  piece  of  sterile  gauze.  It  is  then  washed  with 
alcohol  and  allowed  to  dry.  A  large  sewing-needle  is  sterilized  by 
heating  to  a  red  heat  over  a  lamp  or  a  lighted  match.  The  skin  is 
pulled  taut  without  touching  the  place  to  be  vaccinated  and  lightly 
scarified  criss-cross  without  bleeding,  in  two  places  ^  inch  apart,  each 
being  ^  inch  square;  the  vaccine  is  then  unsealed,  applied  and  gently 
rubbed  in.  It  is  next  allowed  to  dry  for  twenty  minutes,  care  being 
taken  that  it  is  not  contaminated  at  this  time.  When  dry  a  piece  of 
sterile  cotton  or  gauze  is  laid  over  it  and  firmly  fastened  with  strips  of 
adhesive  plaster.  Vaccination  shields  should  not  be  used,  as  much 
contaminating  dust  and  dirt  may  collect  under  them.  The  dressing 
should  not  be  disturbed  except  by  the  physician  for  the  purpose  of 
seeing  if  the  vaccination  is  successful  and  uncomplicated  at  the  end 
of  the  week.  It  should  be  very  secure  in  children  who  are  old  enough 
to  tear  it  off.  Vaccination  should  be  attempted  at  least  three  times 
with  a  different  lot  of  virus  each  time  before  one  should  say  that  the 
child  cannot  be  successful!}^  vaccinated. 

Description  of  Normal  Course. — The  scarified  area  appears  to  be 
healing  with  no  general  symptoms  until  the  third  to  fifth  day,  when  a 
small  papule  develops  at  the  sight  of  inoculation.  This  increases  in  size, 
and  after  one  or  two  days  develops  into  a  large  vesicle  with  a  raised 
margin  and  depressed  center,  the  whole  surrounded  by  a  red  areola. 
By  the  eighth  day  it  has  attained  its  maximum,  and  on  the  tenth  day 
the  contents  are  purulent.  The  surrounding  areola  is  extensive,  swol- 
len, indurated,  and  painful.     The  axillary  or  inguinal  glands,  according 


THE  EXANTHEMATA.  247 

to  the  site  of  vaccination,  are  large  and  tender.  On  the  eleventh  or 
twelfth  day  the  hyperemia  diminishes  and  the  pustule  begins  to  dry 
up,  and  by  the  end  of  the  second  week  only  a  brown  crust  remains; 
this  comes  off  in  another  week,  leaving  a  round,  pitted  scar.  Usually 
on  the  fourth  or  fifth  day  some  fever  and  more  or  less  marked  consti- 
tutional symptoms  develop  and  last  three  or  four  days.  The  vaccina- 
tion has  not  been  successful  unless,  1.  some  reddened  areola  surrounds 
a  typical  vesicle;  2.  there  is  some  swelling  of  the  lymph-glands; 
3.  some,  even  slight,  fever  and  constitutional  symptoms;  4.  there 
should  be  a  permanent  scar  in  which  even  years  after,  numerous  small 
pin-point-sized  depressions  are  seen.  This  last  characteristic  is  very 
valuable  in  determining  the  success  of  a  vaccination  for  a  number  of 
years  after. 

Variations  and  Complications. — The  vesicle  may  abort  and  dry  up 
in  seven  or  eight  days,  in  which  case  revaccination  should  be  practised. 
Generalized  vaccina  at  times  shows  itself  at  the  end  of  the  first  week 
by  a  vesicular  eruption  in  any  part  of  the  body.  It  may  continue  to 
make  its  appearance  for  five  or  six  weeks.  It  is  not  serious,  as  a  rule, 
but  has  been  known  to  be  fatal.  Recurrences  of  the  vesicle  at  the 
site  of  the  original  vaccination  are  rare.  Reinoculation  occurs  in 
children  who  have  scratched  the  original  vesicle  and  then  vaccinated 
themselves  in  different  parts  of  the  body. 

Infection  with  other  organisms  results  from  1.  contaminated 
virus;  2.  lack  of  asepsis  in  vaccination;  3.  traumatism  and  contami- 
nation during  the  vesicular  stage.  If  the  vesicle  is  not  ruptured  it  is 
not  liable  to  be  contaminated,  but  with  a  sterile  dressing  over  it 
there  is  double  protection.  The  results  of  contamination  may  be 
ulceration  more  or  less  severe,  or  even  an  extensive  necrosis;  suppura- 
tion of  the  lymph  nodes;  septicemia  or  suppuration  in  the  joints. 
Tetanus,  syphilis,  and  tuberculosis  are  almost  never  seen  now  that 
animal  lymph  is  used.  Other  complications  are  eczema,  general  urti- 
carial or  scarlatiniform  erythematous  eruptions.  These  may  occur 
from  the  first  to  the  fifth  weeks. 

Varicella. 

(Chicken-pox.) 

Definition. — Varicella  is  a  short,  mild,  contagious  disease,  with  a 
long  period  of  incubation,  a  short  prodromal  stage,  followed  by  an 
eruption  of  superficial  papules  going  on  to  vesiculation. 

Etiology. — No  specific  microorganism  has  yet  been  discovered. 
It  is  an  independent  disease  not  closely  allied  to  small-pox.     It  does 


248  DISEASES  OF  CHILDREN. 

not  protect  from  small-pox,  nor  does  small-pox  protect  from  it.  The 
disease  is  most  common  between  the  ages  of  two  and  six  years,  and 
is  rare  after  puberty.  It  is  communicable  on  slight,  short  contact, 
the  mode  of  entrance  not  being  known. 

Pathology. — The  papule  and  vesicle  is  near  the  surface,  being 
formed  by  the  upper  layer  of  the  epidermis.  The  vesicle  is  seldom 
multilocular,  and  unless  deeper  ulceration  takes  place,  which  occasion- 
ally occurs,  it  does  not  leave  a  scar. 

Incubation. — Ten  to  eighteen  days,  usually  fourteen  days. 

The  prodromal  stage  lasts  about  twentj^-four  hours. 

Description. — After  a  day  of  slight  malaise,  with  perhaps  a  tem- 
perature of  101°  F.  to  102°  F.,  a  few  red  papules,  varying  from  pin-head 
to  pea-size,  are  seen  anywhere  on  the  body.  Usually  they  are  few 
in  number  and  scattered  over  the  face,  trunk,  and  extremities.  The 
temperature  may  be  lowered  a  degree  or  more  after  the  eruption  comes 
out,  but  the  patient  still  has  some  constitutional  symptoms.  A  slight 
sore  throat  is  the  rule,  as  a  few  of  the  same  isolated  red  papules  appear 
on  the  fauces  and  pharynx.  Within  a  few  hours  vesicles  take  the 
place  of  the  papules  which  first  make  their  appearance,  and  at  the 
same  time  another  crop  of  papules  appears  scattered  here  and  there, 
between  them.  This  process  continues  three  or  four  days,  so  that 
at  any  one  time  the  lesions  in  their  various  stages  may  be  seen  as  small 
and  large  papules,  beginning  vesicles,  large  full  rounded  vesicles,  and 
those  that  are  drying  up.  They  may  be  an  inch  or  two  apart,  or 
they  may  be  much  closer  together.  They  usually  have  no  umbilica- 
tion,  feel  soft  to  the  touch,  and  collapse  when  pricked  with  a  needle. 
As  a  rule,  they  do  not  go  on  to  pus  formation,  but  contain  a  clear,  or 
at  most,  a  slightly  turbid  fluid.  After  two  or  four  days  they  dry  up, 
the  temperature  is  normal,  and  convalescence  is  established. 

Variations,  Complications,  and  Sequelae. — Many  children  show 
little  or  no  constitutional  symptoms.  Rarely  there  may  be  a  high 
fever,  even  to  105°  F.,  and  corresponding  symptoms,  but  this  is  the  ex- 
ception. In  some  cases  the  eruption  is  profuse  on  the  vulva  and  nates, 
with  consequent  vesical  and  rectal  tenesmus.  Occasionally  one  or 
two  of  the  vesicles  become  infected  and  more  or  less  deep  destruction 
of  tissue  results.  Cases  of  high  fever  and  pustulation  of  all  the  vesicles, 
lasting  a  week  or  longer,  have  been  reported.  A  depression  in  the 
center  of  each  vesicle,  that  is,  umbilication,  is  not  typical,  but  it  occurs 
often  enough  to  be  misleading  in  differentiating  an  atypical  case  from 
small-pox. 

Albumin  in  the  urine  is  not  uncommon,  but  true  nephritis  is  rarely 
seen,  except  in  an  unusually  severe  case.     Acute  simple  inflammatory 


Chicken-pox. 

10  to  14  days. 

2 

3 
o 

Red  papules  on  palate 
and  fauces. 

Slight  malaise. 

Papules    rarely  hard; 
becoming  vesicular 
in     a     few     hours. 
Seldom  umbilicated 
always  collapsable. 
Individual    lesion 
completes  cycle   in 
2  days. 

Irregular  and  general 
distribution    comes 
in  successive  crops 
.so    that    all    stages 
may  be  seen  at  the 
same  timein  any  one 
locality.     As    thick 
on  trunk  as  on  face. 

Crusts,  no  pitting. 

X 

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a 

£ 

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Red  papules  on  pal- 
ate and  fauces. 

Sudden  onset.     In- 
tense symptoms. 
Backache. 

Hard    shotty    pap- 
ules in  2  days  be- 
coming     umbili- 
cated noncollaps- 
able  vesicles  and 
in    4    days    pus- 
tules. Total  cycle, 
0  days. 

Appears     first     on 
forehead      and 
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face,    then   on 
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on  trunk.     All  in 
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ces and  posterior 
pharyngeal   wall. 
Raspberry  tongue 

Sudden  onset  with 
intense  symptoms 
Sore  throat.  Vom- 
iting. Convulsions 

Uniform    erythema 
with      minute 
puncta. 

Appears     first     on 
cnest,    spreading 
to    rest     of     the 
body.     Least  in- 
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250  DISEASES  OF  CHILDREN. 

involvement  of  the  joints,  lasting  only  a  few  days,  has  been  noted. 
Otitis  and  pneumonia  are  rare  complications. 

Prognosis. — Recovery  to  is  be  expected  after  a  short  mild  illness. 

Treatment. — To  prevent  the  transmission  of  the  disease,  isolation 
from  other  children  should  be  insisted  upon,  for  although  the  disease 
is  mild  it  occasionally  produces  some  serious  consequences.  The  child 
should  be  kept  from  scratching  the  vesicles  to  prevent  infection  by  the 
finger-nails.  An  initial  dose  of  1  gr.  of  calomel,  and  a  liquid  diet  are 
the  only  measures,  as  a  rule,  required  during  the  illness. 

Diphtheria. 

Diphtheria  is  an  acute  infectious  disease  due  to  the  growth  and  ac- 
tion of  the  Klebs-Loeffler  bacillus  on  a  vulnerable  surface  producing 
a  local  membrane  and  general  toxic  symptoms. 

Etiology. — The  disease  is  endemic  in  large  cities.  Local  epidemics 
frequently  occur  in  small  towns  and  villages.  Statistics  show  the 
disease  to  be  more  prevalent  in  the  winter  and  fall  than  in  the  summer 
months.  In  fact,  vacation  periods  show  a  falling  off  in  all  infectious 
and  contagious  diseases.  The  disease  is  contracted  directly  or  indirectly 
from  another  case  of  diphtheria.  The  indirect  means  are  usually 
the  handling  of  infected  objects  and  attendants  who  do  not  take  proper 
precautions.  Even  contaminated  food,  such  as  berries  and  milk,  have 
been  known  to  infect  the  consumer.  There  is  no  discrimination  as 
to  sex;  age,  however,  plays  an  important  part.  Nurslings  possess  con- 
siderable immunity.  The  third  to  fifth  year  is  the  period  of  greatest 
liability.  From  the  tenth  year  to  puberty,  the  susceptibility  markedly 
decreases.  Children  of  the  so-called  "lymphatic  diathesis"  are  par- 
ticularly vulnerable,  as  are  those  who  have  been  weakened  by  pre- 
vious diseases. 

Pathology. — The  pathology  is  in  the  main  that  of  the  pseudomem- 
brane.  This  is  a  true  coagulation  necrosis,  wich  may  be  situated  upon 
the  pharynx,  nasopharynx,  larynx,  or  trachea.  More  rarely  it  is 
found  upon  the  mucous  membrane  of  the  nose,  conjunctiva,  or  vaginal 
membrane.  The  bacillus  or  its  toxins  circulating  in  the  blood  may 
produce  myocardial  changes  of  a  fatty  or  degenerative  nature.  The 
cervical  lymph  nodes  show  a  simple  cell  hyperplasia.  The  involve- 
ments of  the  lungs  and  kidneys  must  be  regarded  as  complications. 

Symptomatology. — The  symptoms  differ  as  they  are  the  results 
of  a  pure  or  a  mixed  infection,  and  as  to  the  anatomical  distribution 
of  the  pseudomembrane.  The  mixed  type  is  usually  an  association  of 
the  Klebs-Loeffler  bacillus  with  the  streptococcus  as  in  scarlatina. 


PLATE  XI. 


Differential  diagnosis  of  (a)  follicular  tonsillitis;  (6)  scarlatinal  angina; 
(c)  diphtheria;  (d)  lacunar  tonsillitis. 


THE  INFECTIOUS    DISEASES,  251 

The  general  symptoms  of  any  of  the  forms  of  diphtheria  are 
dependent  upon  the  degree  of  toxemia.  The  attack  is  usually  ushered 
in  with  vomiting  or  a  chill.  There  is  no  characteristic  temperature 
curve.  The  fever  is  of  a  low  grade,  101°  to  102°  F.,  in  uncomplicated 
cases.  The  pulse  rate  is  increased  in  direct  proportion  to  the  youth- 
fulness  of  the  patient.  Lassitude  or  somnolence  in  various  degrees 
,may  be  observed  before  local  lesions  are  suspected.  The  quantity 
of  urine  is  diminished,  and  traces  of  albumin  are  found  in  a  large 
proportion  of  the  cases.  The  blood  shows  a  hyperleukocytosis, 
especially  in  the  polynuclear  elements.  The  red  blood-cells  and  the 
hemoglobin  are  correspondingly  diminished. 

Diphtheria  (Tonsillar  and  Pharyngeal. — In  this  type  the  clinical 
manifestations  vary  from  those  of  an  extremely  mild  variety  to 
severe  toxic  cases.  The  child  may  not  complain  of  any  sore  throat 
and  the  membrane  may  be  found  only  on  routine  examination.  On 
the  other  hand,  there  may  be  low  fever,  vomiting,  and  some  difficulty 
in  swallowing.  Examination  of  the  throat,  which  should  always  be 
done  with  the  best  possible  light  and  with  a  curved  tongue  depressor, 
may  show  membrane  in  the  form  of  a  grayish-white  patch  on  one  or 
both  tonsils.  The  tonsils  may  be  enlarged  and  congested.  The 
uvula  or  adjacent  pharynx  soon  become  involved  (see  Plate  XI). 
A  grayer  or  dirtier  colored  membrane  is  seen  after  the  third  or  fourth 
day.  In  severer  cases  the  uvula,  posterior  pharynx,  and  fauces  show 
the  characteristic  membrane.  The  general  symptoms  are  now  more 
aggravated,  due  to  the  toxemia;  prostration  is  marked.  The  glands 
of  the  neck  enlarge  and  become  painful.  There  is  dysphagia  and 
difficulty  in  enunication.  There  may  be  delirium.  The  breath  is 
offensive  and  quite  characteristic.  The  pulse  is  rapid  and  feeble. 
The  temperature  is  irregular  and  at  times  high.  If  in  this  form  we 
have  the  added  complication  of  a  mixed  infection  the  toxemic  symp- 
toms are  still  further  aggravated,  becoming  those  of  a  true  sepsis. 
Complications  are  then  apt  to  supervene  early,  and  the  kidneys 
almost  invariably  suffer. 

Differential  Diagnosis  — Tonsillar  diphtheria  must  often  be  dis- 
tinguished from  a  follicular  tonsillitis,  especially  if  the  exudation 
from  the  crypts  has  merged,  and  seemingly  forms  a  membrane.  This 
is  especially  necessary  in  the  absence  of  a  bacteriological  diagnosis. 
(Plate  XI.) 

In  follicular  tonsillitis,  both  tonsils  are  usually  involved  simul- 
taneously. There  is  an  initial  high  temperature  of  104°  to  105°  F. 
Usually  there  is  no  vomiting.  Careful  inspection  will  reveal  isolated 
crypts  distended  with  their  cheesy  detritus.     The  pseudomembrane 


252  DISEASES  OF  CHILDREN. 

can  be  readily  removed.  The  diphtheritic  membrane,  on  the  other 
hand,  adheres  closely  and  leaves  an  excoriated  and  bleeding  surface 
if  forcible  attempts  are  made  to  remove  it.  The  bacteriological 
diagnosis  should  be  made  whenever  feasible,  but  the  returns  should 
not  be  waited  for  except  in  extremely  mild  suspicious  cases.  The 
bacteriological  examination  may  be  made  with  a  smear  prepara- 
tion stained  with  Loeffler's  solution  and  directly  examined,  or  by 
inoculating  the  tube  of  blood  serum  and  examining  the  growth  after 
twenty-four  hours  of  incubation.  The  precaution  should  be  observed 
to  take  the  culture  before  any  antiseptics  have  been  applied,  or  at 
least  within  some  hours  thereafter. 

Laryngeal  Diphtheria. — In  this  form  the  membrane  may  extend 
from  the  nose  or  throat,  or  it  may  primarily  involve  the  larynx. 
In.the  latter  case  there  are  symptoms  due  to  congestion  of  the  mucous 
membrane  of  the  larynx  and  the  vocal  cords;  that  is,  a  hoarse 
inspiratory  cough,  some  restlessness  and  a  low  grade  of  temperature. 
Cultures,  if  taken  at  this  stage,  are  usually  found  to  be  negative, 
especially  if  a  laryngeal  swab  is  not  correctly  used.  As  the  disease 
progresses  symptoms  of  obstruction  are  apparent,  due  to  the  forma- 
tion of  the  laryngeal  membrane  which  is  sometimes  visible  about 
the  epiglottis.  The  cough  is  more  aggravated  and  paroxysmal  in 
character;  the  patient  acts  as  if  attempting  to  dislodge  an  irritating 
foreign  body.  There  is  partial  or  complete  aphonia  with  a  muffled 
or  suppressed  cough  and  whispering  voice.  The  accessory  muscles 
of  respiration  are  brought  into  requisition.  The  periods  of  remission 
from  coughing  become  shorter  and  shorter  in  duration,  and  are  easily 
brought  on  by  disturbing  the  patient.  If  the  child  falls  into  a  restless 
sleep,  the  symptoms  are  less  noticeable,  but  do  not  in  any  sense 
resemble  the  normal. 

The  pause  between  inspiration  and  expiration  is  noticeably 
prolonged.  The  supraclavicular,  epigastric,  and  diaphragmatic  spaces 
show  marked  recession  at  the  height  of  inspiration.  The  mucous 
membranes  and  nails  are  cyanosed.  Unless  relief  is  now  obtained, 
extreme  restlessness  sets  in,  and  the  child  attempts  in  every  way 
to  get  air;  it  is  markedly  cyanosed,  a  cold  perspiration  appears  on 
the  forehead,  stupor  supervenes  with  spasmodic  breathing,  apnea,  and 
death. 

In  certain  cases  the  membrane  may  extend  to  the  trachea,  even 
beyond  the  bifurcation  of  the  bronchial  tube  (see  Fig.  69). 

Differential  Diagnosis. — We  have  abandoned  the  term  croup  as 
applied  to  diphtheria  as  it  only  tends  to  misleading  conceptions,  and 
perhaps  to  serious  mistakes  in  management.     Clinically,  the  diagnosis 


THE  INFECTIOUS    DISEASES.  253 

should  be  based  upon  the  character  of  the  cough,  the  aphonia,  the 
muffled  cry,  the  progressive  signs  of  laryngeal  obstruction,  and  the 
recession  of  the  thoracic  spaces.  In  non-diphtheritic  laryngitis  the 
child  is  taken  suddenly  ill  at  night  with  an  attack  of  suffocation  and  a 
brassy,  barking  cough.  Ordinary  remedial  measures,  such  as  steam 
inhalations  and  emetics,  give  speedy  relief,  with  the  resumption  of 


Fig.  69. — Cast  of  the  trachea  and  bronchi  expelled  from  a  case 
of  laryngeal  diphtheria. 

normal  breathing  and  apparent  health  during  the  next  twelve  to 
twenty-four  hours,  when  a  second  milder  attack  ma}'  supervene. 
Edema  of  the  lungs,  especially  when  it  early  complicates  a  broncbo- 
pneumonia,  may  simulate  an  attack  of  laryngeal  diphtheria.  The 
physical  signs  must  be  depended  upon  to  clear  up  the  diagnosis. 

Nasal  Diphtheria. — This  form  is  usually  seen  in  children  of  the 
school  age,  and  unfortunately  the  cases  are  not  recognized  and  isolated 
as  early  as  they  should  be.  Children  with  nasal  diphtheria  are 
undoubtedly  great  carriers  and  disseminators  of  the  infection.     The 


254  DISEASES  OF  CHILDREN. 

disease  should  be  suspected  in  cases  of  intractable  or  aggravated 
rhinitis  in  which  there  is  a  mucopurulent,  blood-tinged  discharge, 
accompanied  by  evidences  of  nasal  obstruction.  The  nostrils  and 
upper  lip  are  often  excoriated.  The  children  are  not  sick  enough  to 
want  to  go  to  bed  and  may  have  little  or  no  fever.  The  use  of  the 
nasal  speculum  will  often  show  the  membrane  in  the  nares.  It  is 
usually  in  shreddy  patches  rather  than  in  firm  membranous  masses. 
The  glands  at  the  angle  of  the  jaw  are  moderately  enlarged.  A 
culture  should  be  made  in  all  suspicious  cases. 

If  the  posterior  nares  is  involved  by  extension  from  the  pharynx, 
the  prognosis  is  graver,  as  it  tends  to  lessen  the  respiratory  ability 
and  the  willingness  of  the  child  to  take  food.  The  toxemia  is  likewise 
greater,  and  the  cardiac  muscle  soon  weakens. 

Conjunctival  Diphtheria. — As  in  the  other  forms,  this  may  be 
primary  or  secondary  to  the  disease  of  the  nose  or  throat.  The 
course  is  extremely  rapid.  There  may  be  a  profuse  purulent  discharge 
Avith  marked  edema  of  the  eye-lid;  the  conjunctiva  is  clouded  with  a 
thin  membrane  of  a  gray  color  which  adheres  closely  and  bleeds  easily 
if  attempts  at  removal  are  made. 

These  local  symptoms  are  accompanied  by  an  increase  in  the  tem- 
perature and  pulse  rate  and  by  somnolence  due  to  the  toxemia. 

Complications. — The  respiratory  tract,  the  nervous  system  and 
the  heart  are  the  greatest  sufferers  from  the  toxemia  of  diphtheria. 
Pneumonia  is  a  frequent  complication,  especially  in  badly  nourished 
children  or  in  those  that  have  been  intubated.  The  mixed  infections 
predispose  to  this  complication,  especially  in  those  under  two  years 
of  age.  Postdiphtheritic  paralysis  occurs  in  about  one-fifth  to  one- 
seventh  of  all  cases.  The  common  form  is  the  local  paralysis  of  the 
palatal  group  of  muscles;  it  may  come  on  early  or  late  in  convalescence. 
The  symptoms  are  regurgitation  of  liquids  through  the  nose,  dysphagia, 
and  dysarthria.  The  uvula  is  found  relaxed  and  not  supported  by  its 
muscles.  In  the  severer  forms  the  physiological  action  of  the  pharynx 
and  larynx  is  disturbed.  The  muscles  of  the  lower  extremities  and  the 
eye  may  be  involved  in  the  paralysis.  The  patellar  reflexes  are  lost, 
and  there  may  be  anesthesia  of  the  lower  extremities.  Only  rarely  is 
there  paralysis  of  the  upper  extremity  as  a  part  of  the  general  paralysis. 
If  the  branches  of  the  vagus  are  involved  cardiac  irregularity  is  noticed, 
and  vomiting  and  pains  in  the  abdomen  are  complained  of  by  older 
children.  There  is  a  tendency  to  sudden  death  in  these  cases.  Neph- 
ritis occurs  as  a  result  of  the  toxemia  and  as  it  often  appears  insidi- 
ously without  puffiness  or  anasarca,  the  urine  should  be  carefully 
watched. 


THE  INFECTIOUS   DISEASES.  255 

Prognosis. — This  must  be  formed  by  a  consideration  of  the  patient's 
age,  his  resistance,  the  location  of  the  membrane,  whether  of  the 
pure  or  of  the  mixed  type,  and  the  time  of  the  serum  administra- 
tion. The  following  are  the  mortality  statistics  from  the  Boston  City 
Hospital.  ^^BP/:iy 

(Cases  treated  with  antitoxin.)  ^  /) 

Under  five  years,  20  per  cent,  of  all  cases.  '  ^  //lr> 

Five  to  ten  years,  8  per  cent,  of  all  cases.  ^^    D 

Ten  to  fifteen  years,  3  per  cent  of  all  cases. 

Exclusively  nasal  cases  offer  the  best  prognosis.  Uncomplicated 
tonsillar  or  pharyngeal  cases  rank  next  in  a  good  prognosis.  Laryn- 
geal cases  are  the  least  favorable,  especially  when  the  necessity  arises 
for  intubation  or  tracheotomy.  In  private  practice,  where  the  cir- 
cumstances are  the  most  favorable,  the  mortality  has  been  reduced  to 
less  than  one-third  of  all  cases.  Antitoxin  has  been  the  means  of 
reducing  all  the  mortality  statistics;  and  if  given  before  the  fourth 
day  of  the  disease  the  prognosis  is  very  favorably  influenced. 

Treatment. — The  management  may  be  divided  into  the  prophy- 
lactic, general,  serum,  local,  and  operative  treatment. 

Prophylactic. — Immunization  with  antitoxin  assumes  the  first 
place  in  prophylactic  treatment.  The  immunity  lasts  from  three  to 
four  weeks  and,  as  conclusively  proven  by  the  statistics  from  the  New 
York  Board  of  Health  and  elsewhere,  has  saved  many  lives.  Thir- 
teen thousand  persons  received  immunizing  injections  through  the 
New  York  Department  of  Health;  of  these  only  three-tenths  of  1  per 
cent,  had  a  subsequent  mild  grade  of  diphtheria,  and  there  was  only 
one  death.  Immunizing  doses  of  500  to  1,000  units  should  be  given 
to  all  the  susceptible  individuals  in  a  family  who  have  been  exposed. 
In  hospitals  or  institutions  patients  may  be  immunized,  especially  if 
measles  are  epidemic.  All  true  cases  and  suspected  cases  should  be 
carefully  isolated,  and  disinfection  practised  as  is  indicated  in  the 
special  article  on  this  subject  (page  312), 

General  Treatment. — The  child  should  be  placed  in  bed  in  a  well 
ventilated,  sunlit  room,  capable  of  separation  from  the  rest  of  the  house. 
Cool  liquid  or  semisolid  foods,  such  as  milk,  ice  cream,  junket,  etc., 
should  be  offered  at  short  intervals.  Cold  compresses  are  useful 
to  mitigate  the  dysphagia,  while  light  ice-bladders  are  often  agree- 
able and  efficacious  when  applied  to  the  neck,  particularly  in  glandular 
cases.  The  bowels  should  be  kept  open  with  calomel  or  salines. 
The  urine  should  be  examined  at  least  bi-weekly.  Strychnin  sul- 
phate in  doses  of  from  277  to  y^^  of  a  grain,  according  to  the  age  of 
the  child  and  the  necessity  for  stimulation,  may  be  given  every  two 


256  DISEASES  OF  CHILDREN. 

to  three  hours.  Whisky  may  be  alternated  with  the  strychnia  in 
toxemic  cases  with  irregular  heart  action  or  bradycardia.  Small 
doses  of  morphine  ^jf  to  ^^  of  a  grain  are  often  efficacious  in  control- 
ling the  restlessness,  and  at  the  same  time  acting  as  a  tonic  to  the  heart. 
Infusions  of  normal  saline  solution  have  been  of  material  assistance 
in  saving  desperate  cases.  Bromid  of  sodium  if  not  contraindicated 
by  the  heart's  action  is  of  value  as  an  antispasmodic  before  extuba- 
tion  in  laryngeal  cases.  Paregoric  or  Dover's  powder  in  small  doses 
maj^  be  given  for  the  same  purpose. 

Serum  Treatment. — Antitoxin  should  be  given  in  all  cases  of  diph- 
theria or  those  suspected  of  being  diphtheritic.  In  its  improved  form 
there  are  no  contraindications  to  its  use.  Two  thousand  units 
should  be  given  in  mild  cases  of  faucial  or  nasal  diphtheria,  and  re- 
peated with  a  double  dose  in  twenty-four  hours  if  the  false  membrane 
has  not  shown  signs  of  disappearing;  three  to  five  thousand  units  may 
be  the  initial  dose  in  severer  cases.  In  laryngeal  diphtheria  5,000  units 
in  infants  and  10,000  units  in  older  children  should  be  given  at  once. 
The  dose  should  be  repeated  in  twelve  hours  in  cases  of  stenosis  if 
the  respiratory  difficulty  is  not  ameliorated.  Larger  doses  must  be 
given  if  the  disease  is  seen  in  its  later  stages.  Immunization  is  satis- 
factorily accomplished  with  injections  of  500  to  1,000  units,  according 
to  the  age  of  the  child. 

The  loose  tissues  under  the  pectoral  region  or  over  the  right  or 
left  iliac  region  may  be  selected  for  the  site  of  the  injection.  The 
skin  is  made  surgically  clean,  and  the  antitoxin  injected  with  a  large 
sterile  syringe  and  needle.  The  wound  should  be  sealed  with  collod- 
ion. The  pseudomembrane  after  the  injection  of  antitoxin  slowly 
tends  to  detach  itself.  In  laryngeal  cases,  in  which  the  membrane  is 
not  seen,  the  decreasing  symptoms  of  obstruction  give  evidences  of 
its  good  effects.  The  hypertrophied  lymph  nodes  decrease  in  size, 
and  the  general  symptoms  are  all  improved.  An  eruption  in  the 
form  of  an  erythema  or  urticaria  sometimes  follows  the  injection  of 
antitoxin.  This  is  attributable  to  the  horse,  serum  itself.  A  scarla- 
tiniform  or  macular  rash  is  occasionally  observed.  The  improved 
concentrated  preparations  rarely  produce  skin  manifestations.  We 
have  successfully  used  the  serums  prepared  by  Mulford  &  Co.,  Parke 
Davis  &  Co.,  and  the  New  York  Board  of  Health. 

Local  Treatment. — The  curative  effect  of  antitoxin  has  superseded 
the  use  of  the  strong  antiseptics  which  were  formerly  locally  applied 
to  the  membrane.  In  older  children  (those  who  can  gargle)  the  use 
of  a  mild  antiseptic  solution,  such  as  diluted  Dobell's  solution,  listerine, 
or  a  comuKm  salt  solution,  will  assist  in  removing  the  loosened  mem- 


THE  INFECTIOUS  DISEASES. 


257 


brane.  Younger  children  are  markedly  benefited  by  irrigations  of  salt 
solution  especially  in  nasal  diphtheria  (half  a  dram  to  the  pint)  used 
at  a  temperature  between  100°  F.  and  115°  F.  An  ordinary  fountain 
bag  is  used,  placed  about  two  feet  above  the  patient's  head,  who 
lies  on  his  side,  prepared  as  for  intubation  (see  Fig.  70).  A 
small  nozzle  is  then  placed  in  one  of  the  patient's  nostrils  and  the 
water  allowed  to  flow  for  a  minute  or  two,  with  intermissions  to  allow 
for  expulsion  and  breathing.  If  done  in  this  way,  the  child  soon 
becomes  accustomed  to  the  process  and  is  not  badly  frightened,  and 
much  relief  is  obtained.  In  certain  cases  the  nozzle  may  be  inserted 
behind  the  back  teeth,  and  the  mouth  thus  irrigated.  If  the  bag  is 
not  placed  too  high  the  pressure  will  not  be  sufficient  to  carry  infection 
through  the  Eustachian  tube. 


FxG  70. — Position  of  the  patient  in  intubation. 


An  ice-bag  applied  to  the  neck  in  cases  of  tonsillar  diphtheria 
affords  relief  and  tends  to  inhibit  the  growth  of  the  membrane,  and  to 
reduce  the  swollen  lymph  nodes. 

Laryngeal  cases  are  often  relieved  by  swabbing  away  the  col- 
lected material  at  the  head  of  the  tube,  an  ordinary  laryngeal  appli- 
cator being  used  for  this  purpose.  Diphtheria  affecting  the  con- 
junctiva must  receive  as  close  attention  as  a  case  of  gonorrheal 
conjunctivitis  besides  the  injection  of  large  doses  of  antitoxin. 

Intubation. — Intubation  or  the  relief  of  laryngeal  stenosis  by  the 
insertion  of  a  tube  was  perfected  by  Dr.  Joseph  O'Dwyer,  of  New 
17 


258 


DISEASES  OF  CHILDREN. 


York,  in  1883.  The  brilliant  results  obtained  have  brought  this 
means  of  relief  into  universal  favor  almost  to  the  exclusion  of  trache- 
otomy which  is  now  rarely  practised. 

The  indications  for  performing  intubation  are  as  follows:  Intu- 
bation should  be  performed  in  laryngeal  diphtheria  when  there  is 
marked  dyspnea,  restlessness,  retraction  of  the  epigastric  and 
supraclavicular  spaces  with  evidences  of  cyanosis. 

The  child  is  prepared  by  being  closely  wrapped  and  pinned  in  a 
sheet  (Fig.  70).     The  operation  may  be  performed  in  a  horizontal 


Fig.  71  — O'Dwyer's  intubation  instruments  with  detachable  parts, 
in  an  aseptic  case. 

position  on  a  table  or  in  an  upright  position  with  the  child's  head 
resting  against  an  assistant's  shoulder.  A  second  assistant  is  required 
to  hold  the  head  in  the  median  line  and  to  keep  the  mouth  gag  in 
place,  as  rapidity  and  a  certain  amount  of  dexterity  are  necessary. 
Practice  upon  the  cadaver,  and  if  possible  upon  the  living  subject, 
should  be  had  under  the  instruction  of  an  experienced  operator.  The 
instruments  used  are  generally  those  of  the  O'Dwyer  pattern,  as  they 
conform  most  accurately  to  the  anatomy  of  the  region.  They  are 
now  made  of  hard  rubber,  metal  lined,  in  sizes  according  to  the  age 
of  the  child.  The  neck  of  the  tube  is  held  within  the  vocal  cords, 
while  its  lower  end  extends  almost  to  the  bifurcation  of  the  trachea 


THE  INFECTIOUS  DISEASES.  259 

An  introducer,    an   extubator,    the   tubes,   a   mouth   gag   and  scale 
complete  the  set. 

The  proper  tube  having  been  selected,  a  loop  is  made  by  threading 
a  piece  of  strong  silk  through  the  eyelet  placed  in  one  side  of  its  head. 
The  child  is  firmly  held  by  its  head  and  its  extremities  kept  from 
moving  by  a  second  assistant  when  on  a  table,  or  by  the  knees  of  the 


Introducer,  with  obturator  and  tube  in  place. 


assistant  who  holds  the  patient  in  his  lap.  The  left  index-finger  is 
inserted  and  the  epiglottis  found  and  firmly  held  forward.  The 
palmar  surface  of  the  finger  should  be  presented  to  the  tube.  At 
first  the  handle  of  the  introducer  is  held  parallel  to  the  child's  body; 
it  is  then  raised  until  the  tube  passes  between  the  vocal  cords,  when 
it  will  be  beyond  a  right  angle  to  the  body  of  the  child.  The  trigger 
of  the  introducer  is  now  used  which  allows  the  body  of  the  tube  to 
pass  well  beyond  the  vocal  cords,  the  finger  at  the  head  of  the  tube 


Fig.  73.— Extractor. 


gently  forcing  it  into  place  while  the  obturator  is  being  removed. 
The  cord  is  still  kept  in  place,  but  the  mouth  gag  should  be  quickly 
removed.  A  metallic  cough  and  the  relief  of  the  symptoms  of  stenosis 
will  be  the  proof  of  success.  A  series  of  expulsive  efforts  followed  by 
free  inspiratory  effort,  disappearance  of  cyanosis,  and  a  period  of 
calm  and  rest  for  the  child  will  follow. 


260 


DISEASES  OF  CHILDREN. 


Fig.  74. — Intubation  tubes.     I,  Granulation  or  built-up  tabes;  II,  ordinary 
tube  (lateral  view);  III,  ordinary  tube  (front  view). 


P"iG.  75. — The  forefinger  holding  the  head  of  the  tube  in  position  as  the 
obturator  is  removed,     {\orthiup  and  Nicoll.) 


THE  INFECTIOUS  DISEASES. 


261 


Failure  may  result  because  the  operator  has  not  kept  closely  to 
the  dorsum  of  the  tongue  in  passing  his  tube,  or  because  he  has  failed  to 
keep  the  handle  of  his  instrument  parallel  to  the  child's  body  in  the 
first  movement  toward  the  epiglottis.  In  rare  instances  a  certain 
amount  of  membrane  is  pushed  down  before  the  tube,  and  as  a  result 
there  is  no  relief,  or  there  may  be  an  increase  in  the  stenotic  symptoms. 
The  child  should  then  be  held  in  an  inverted  position,   when  the 


/ 


Fig.  76. — Extubation. 


membrane  usually  is  expelled,  and  the  tube  may  then  be  reinserted. 
If  any  force  is  used  damage  may  be  done.  The  cord  may  be  removed 
after  some  minutes  by  placing  the  finger  on  the  head  of  the  tube  and 
withthawing  it,  or  it  may  be  fastened  on  the  side  of  the  face  with 
adhesive  plaster. 

Extubation. — This  should  be  performed  as  soon  as  there  are 
evidences  of  marked  improvement  in  the  general  condition  of  the 
patient  as  shown  by  decreased  toxic  symptoms,  and  a  marked  decrease 
in  the  laryngeal  obstruction.     This  may  occur  on  the  third,  fifth,  or 


262  DISEASES  OF  CHILDREN. 

seventh  day,  depending  upon  the  severity  of  the  case,  upon  the  early 
use  of  the  antitoxin,  and  upon  the  age  of  the  child.  Children  under 
two  years  of  age  cannot,  as  a  rule,  be  extubated  as  soon  as  older  children. 

If  cyanosis  follows  the  removal  of  the  tube,  it  must  be  quickly 
replaced,  all  the  preparations  having  been  made  for  this  possibility. 
Special  tubes  with  built-up  heads  and  retention  swells  are  used 
in  cases  demanding  prolonged  intubation  (Fig.  74).  They  act  by 
preventing  and  causing  destruction  of  the  granulation  tissue. 

The  Feeding  of  Intubated  Cases. — Older  children  soon  manage  to 
take  fluids  and  semifluids  without  much  difficulty.  Infants  and 
younger  children  may  be  fed  in  a  prone  position,  or  with  the  head 
■  lower  than  the  body,  being  fed,  if  necessary,  by  a  bottle  or  medicine 
dropper  for  a  few  days.  Feeding  by  gavage  may  occasionally  be 
necessary. 

Tracheotomy. 

Indications  for  Tracheotomy. — Tracheotomy  should  be  performed 
in  those  cases  in  which  intubation  has  failed  and  the  membranes  are 
forced  further  down  into  the  larynx.  In  cases  in  which  the  membrane 
forms  below  the  tube  and  no  relief  is  obtained,  and  in  cases  of  edema 
of  the  glottis  in  which  there  is  extensive  infiltration. 

It  may  here  be  mentioned  that  intubation  is  far  preferable  to 
tracheotomy,  and  the  latter  operation  should  be  performed  only  as  a 
last  resort  or  in  those  rare  cases  in  which  a  proper  tube  is  not  retained. 

The  operation  should  be  performed  under  a  light  general  anes- 
thetic. The  patient  should  be  prepared  as  for  any  aseptic  operation  if 
the  circumstances  allow,  the  neck  being  extended  over  a  sand-bag  and 
kept  in  the  median  line.  An  incision  one  to  one  and  a  half  inches  long 
is  made  through  the  subcutaneous  tissue,  and  then  the  facia  and  sterno- 
hyoid muscles  are  separated.  The  engorged  venus  plexus  is  pushed 
to  one  side  and  the  trachea  exposed.  By  means  of  a  bistoury  an 
opening  is  made  sufficiently  large  to  admit  the  cannula.  (An  instru- 
ment which  will  at  once  incise  and  dilate  the  tracheal  wound  is  now 
on  the  market.) 

When  free  respiration  is  established,  the  cannula  is  fastened  in 
place  by  tapes  about  the  neck,  and  the  wound  dressed  with  moist  gauze. 
A  steam  atomizer  to  moisten  the  respired  air  is  helpful.  The  attend- 
ant should  diligently  remove  the  tracheal  secretions  deposited  upon 
the  pledgets  of  moistened  gauze.  The  inner  tube  of  the  cannula  should 
be  removed  and  thoroughly  cleansed  three  or  four  times  a  day,  or 
whenever  it  is  obstructed.     After  the  third  or  fourth  day  an  attempt 


THE  INFECTIOUS  DISEASES.  263 

may  be  made  to  permanently  remove  the  cannula.     If  the  patient  can 
get  along  without  it,  the  wound  is  cleansed,  dressed,  and  allowed  to  heal. 


Pertussis. 

(Whooping-cough.) 

Pertussis  is  an  acute  infectious  disease  characterized  by  a  par- 
oxysmal cough  that  consists  of  repeated  expirations  ending  in  an  in- 
spiratory whoop  which  is  often  followed  by  vomiting.  Owing  to  its 
complications  it  must  be  classed  as  one  of  the  dangerous  diseases  of 
early  life. 

Etiology. — No  specific  organism  has  as  yet  been  found  which  can 
be  said  to  be  the  true  etiological  factor.  The  secretion  is  apparently 
the  means  of  transmission  from  one  individual  to  another  and  is  very 
communicable.  Clothing  and  the  rooms  of  the  patient  do  not  seem 
to  carry  or  retain  the  infective  agent.  Sporadic  cases  are  constantly 
seen  in  large  centers,  and  epidemics  frequently  occur  both  in  urban  and 
in  rural  districts.  Whooping-cough  is  no  respecter  of  age.  It  has  oc- 
curred in  the  newly-born  and  in  well-advanced  adult  life.  Children 
under  two  years  of  age  show  the  greatest  susceptibility,  while  sucklings 
are  in  some  cases  immune.  The  period  of  incubation  is  from  seven  to 
fourteen  days.  The  primary  stage  is  probably  the  time  of  greatest 
danger  to  others. 

Pathology. — The  larynx  and  trachea  show  a  marked  congestion 
and  exudative  inflammation  of  their  mucous  membrane.  In  fatal 
cases,  areas  of  emphysematous  lung  are  commonly  found.  Subcon- 
junctival and  cerebral  hemorrhages  have  been  found. 

Symptomatology. — For  purposes  of  convenience  in  description, 
the  disease  may  be  divided  into  three  stages.  Namely,  the  primary 
(in  which  the  mucous  membranes  of  the  nose,  larynx  and  trachea  are 
inflamed),  the  spasmodic  stage,  and  the  period  of  recession.  These, 
however,  merge  into  each  other  and  are  not  sharply  defined. 

Primary  Stage. — The  exposed  child  after  a  varying  period  from 
two  days  to  two  weeks  may  have  suffused  eyes,  there  may  be  a  rhinitis, 
and  a  congestion  of  the  pharynx  is  often  seen  on  examination.  The 
child  does  not  feel  sick,  but  coughs  severely,  especially  at  night.  It 
is  described  as  having  a  croupy  character.  After  a  few  days  it  becomes 
more  pronounced  at  night  and  more  frequent  in  the  day  time.  Physi- 
cal examination  at  this  time  may  give  no  evidences  of  bronchitis  if 
this  is  suspected.  These  negative  signs  are  valuable  in  leading  to  the 
true  diagnosis.     An  increase  in  the  mononuclear  leukocytes  is  quite 


264  DISEASES  OF  CHILDREN. 

frequently  found  at  this  time.  A  tongue  depressor  irritating  the 
pharynx  will  sometimes  produce  the  characteristic  whoop,  and  thus 
confirm  the  diagnosis.  A  rise  of  one  or  two  degrees  of  temperature 
is  sometimes  observed,  especially  when  there  is  an  accompanying 
bronchitis. 

Spasmodic  Stage. — This  is  so  named  because  of  the  paroxysmal 
cough  or  whoop  which  follows  the  several  expiratory  efforts.  The 
child  realizing  the  approach  of  a  paroxysm,  seeks  support  from  its 
attendant  or  clings  to  some  article  of  furniture.  There  are  three  or 
four  violent  expiratory  efforts,  followed  by  a  period  of  apnea,  and 
then  the  tremendous  inspiratory  effort  is  made  which,  entering  through 
a  partially  closed  glottis,  causes  the  so-called  whoop.  During  this 
effort  the  eyes  have  become  congested,  the  face  almost  cyanosed,  mucus 
streams  from  the  nostrils,  and  a  mass  of  mucopurulent  secretion  follows 
the  whoop.  Vomiting  occurs  if  there  is  any  food  in  the  stomach. 
Relief  now  comes  to  the  exhausted  patient,  and  after  a  brief  period  of 
rest,  during  which  there  is  sweating  of  the  forehead  and  face,  the  child 
goes  back  to  its  play.  These  attacks  may  occur  ten  or  even  a  hun- 
dred times  a  day.  Naturally,  the  nutrition  soon  suffers;  the  face  may 
later  become  edematous  or  puffy,  masking  the  malnutrition  of  the 
body.  Severe  cases  may  have  subconjunctival  hemorrhages  or  bleed- 
ing from  the  nose  or  lungs.  The  urine  may  show  traces  of  albumin 
and  hyalin  casts.  Convulsions  sometimes  follow  an  exceptionally 
severe  paroxysm,  especially  in  infancy.  In  young  infants  the  spas- 
modic stage  begins  very  soon  after  the  beginning  of  the  attack  and  the 
"whoop"  may  be  absent. 

Recession  of  symptoms  is  shown  by  a  decrease  in  the  number  and 
severity  of  the  paroxysms,  ending  in  a  cough  which  persists  for  several 
weeks. 

Complications, — Bronchopneumonia  frequently  complicates  per- 
tussis, especially  in  infancy.  This  is  the  result  of  an  infective  process 
made  possible  by  the  abnormal  condition  of  the  bronchial  tubes  and 
the  lowered  vital  resistance.  It  generally  occurs  at  the  end  of  the  par- 
oxysmal stage.  Bronchitis  and  emphysema  are  complications  more 
frequently  seen  in  older  children.  Tuberculosis  not  infrequently  fol- 
lows in  the  wake  of  pertussis.  It  may  be  localized  (from  latent  bron- 
chial lymjih  nodes)  or  even  a  general  miliary  tuberculosis  may  result, 
Severe  attacks  of  vomiting  reduce  the  general  nutrition  and  predis- 
pose to  more  important  complications.  Convulsions  result  from  con- 
gestion of  the  l)i-ain,  or  from  minute  capillary  hemorrhages  which  may 
occur  during  the  paroxysm.  We  have  seen  hemiplegia  due  to  men- 
ingnl    apoplexy   follow  a  severe    paroxysm.      Hemorrhages   into   the 


THE  INFECTIOUS  DISEASES.  265 

conjunctiva  and  hernias  in  various  parts  of  the  body  also  result  from 
the  severe  strain  imposed  by  the  paroxysms. 

Course  and  Prognosis. — In  some  cases  the  disease  lasts  only  a 
week  or  two,  but  on  the  other  hand,  we  have  seen  it  persist  beyond 
three  months.  If  complications  occur  it  is  more  apt  to  be  prolonged. 
The  mortality  of  this  disease  and  its  complications  is  higher  than  is 
generally  appreciated.  Infants,  especially,  are  prone  to  fatal  attacks 
of  pneumonia,  convulsions,  and  tuberculosis.  Among  the  poor  where 
undernourished  children  are  most  likely  to  be  found  the  mortality  is 
high. 

The  prognosis  is  based  upon  the  general  condition  of  the  child, 
the  number,  and  character  of  the  daily  paroxysms,  and  its  ability  to 
retain  food. 

Treatment. — Although  whooping-cough,  like  the  other  infectious 
diseases,  is  self-limited,  its  severity  can  be  considerably  modified  and  its 
complications  often  prevented  by  appropriate  treatment. 

Aero  therapy. — The  child  should  spend  the  greater  part  of  the 
day  out  of  doors  in  pleasant  weather.  If  the  circumstances  permit 
removal  to  the  seashore  it  is  of  undoubted  benefit.  The  fine  saline 
particles  thrown  up  by  the  surf  give  quick  relief  by  being  inhaled. 
The  sleeping-quarters  should  be  well  ventilated,  the  child  being  pro- 
tected by  screens  from  direct  draughts. 

Drugs. — For  the  control  of  the  cough  in  the  beginning  of  the 
spasmodic  stage  we  have  had  very  satisfactory  results  with  the  three 
following  drugs,  fluoroform,  the  bromids,  and  antipyrin.  The  treat- 
ment may  be  begun  by  giving  two  drops  of  a  2.8  per  cent,  solution 
of  fluoroform  every  two  hours  during  the  day,  and  after  each  paroxysm 
during  the  night,  to  a  year-old  child.  The  dose  may  be  increased  by 
one  drop  for  each  succeeding  year  of  age.  Occasionally  this  is  not 
effectual  enough,  or  apparently  the  child  becomes  accustomed  to  its 
sedative  action.  The  bromid  of  soda  in  two-grain  doses  every  three 
hours  for  a  two-year-old  child  may  be  substituted.  Antipyrin  is 
well  tolerated,  and  can  safely  be  prescribed  if  complications  do  not 
contraindicate.  It  may  also  be  combined  with  the  bromids  as  in 
the  prescription  given  below.  A  child  of  six  months  can  be  given  A 
grain  of  antipyrin  at  three-hour  intervals,  2  grains  to  a  two-year-old 
child.  If  it  is  used  with  the  bromids  the  dosage  must  be  regulated 
accordingly. 

In  exceptional  instances  in  which  the  paroxysms  are  particularly 
severe  and  are  preventing  rest,  small  doses  of  heroin,  as  indicated  in 
the  prescription  below,  will  give  relief  for  the  night. 


266 


DISEASES  OF  CHILDREN. 


Fig.  77. — The  Kilmer  belt  for  pertussis. 


THE  INFECTIOUS  DISEASES.  267 

For  a  two-year-old  child: 

I^    Antipyrini gr.xxxij 

Glycerini 3iij 

Aquae q.  s.  ad.  3ij 

Misce  et  signa. — One  teaspoonful  every  three  hours 
for  six  doses. 

I^     Sodii  bromidi gr.  xlv 

Antipyrini gr.  xxiv 

Glycerini    3iij 

Aquae q.  s.  ad.  §ij 

Misce  et  signa. — One  teaspoonful  every  three  hours 
for  a  three-year-old  child — well  diluted. 

1^     Heroini  hydrochloridi gr.  f 

Antipyrini gr.  xvj 

Elixiris  adjuvantis 5ij 

Misce  et  signa. — A  teaspoonful  every  three  hours  to 
a  child  of  two  years  for  three  doses. 

Diet. — Food  should  be  taken  in  smaller  quantities  and  at  lessened 
intervals  than  in  health.  This  measure  in  itself  prevents  the  vomiting 
which  readily  occurs  when  a  full  meal  is  taken.  After  vomiting,  a 
cup  of  milk  or  meat  broth  may  be  immediately  given.  Only  simple, 
light  and  nutritious  articles  should  be  permitted  in  the  dietary. 

The  inhalation  of  antiseptics  has  given  us  no  satisfactory  results. 
In  fact,  it  tends  to  encourage  poor  ventilation  in  the  sleeping  apart- 
ment. A  belt  as  suggested  by  Kilmer  can  be  worn  if  vomiting  is 
frequent.  In  a  certain  number  of  cases  this  appliance  (see  Fig.  77) 
has  given  relief  from  this  distressing  symptom. 


Mumps. 
(Epidemic  Parotitis.) 

Mumps  is  an  acute  communicable  disease  of  the  salivary  glands, 
characterized  by  a  swelling  of  the  parotid  gland  and  the  neighboring 
salivary  glands,  and  at  times  involving  the  testis  or  ovary. 

Etiology. — Children  from  two  to  fifteen  years  of  age  are  most 
often  affected.  Epidemics  are  common  in  schools  and  institutions. 
The  specific  contagium  has  not  been  isolated.  Close  contact  is 
necessary  for  its  dissemination,  but  the  disease  is  transmissible  before 
the  swelling  appears.  The  portal  of  entry  seems  to  be  the  buccal 
cavity.  The  period  of  incubation  is  an  indeterminate  one;  it  ranges 
from  one  to  four  weeks.  Immunity  is  generally  conferred  by  the  one 
attack.     Recurrences,  however,  do  occur. 

Pathology. — According  to  Virchow,  there  is  an  inflammatory 
serous  and  cellular  infiltration  of  the  intraacinous  and  periacinous 
connective  tissue,  which  tends  to  resolution  without  induration. 


268  DISEASES    OF    CHILDREN. 

Symptomatology. — In  children  the  onset  is  usually  mild,  with  a 
period  of  malaise,  drowsiness,  fever  of  one  or  two  degrees  (only  rarely 
104°  F.),  chilliness,  and  sometimes  vomiting.  A  swelling  now  appears 
below  the  lobe  of  the  ear  on  one  side  of  the  face  and  in  a  few  days  the 
opposite  gland  is  generally  involved.  The  child  complains  of  a 
feeling  of  fullness,  with  pain  localized  in  the  angle  of  the  jaw.  The 
swellings  are  elastic  on  palpation.  Mastication  is  difficult  and  food 
may  be  refused  for  this  cause.  The  fever  ranges  from  101°  to  103°  F. 
Occasionally  there  is  earache  or  deafness.  The  swelling  may  extend 
over  the  parotid  in  front,  or  involve  the  submaxillary  gland  and  the 
neighboring  lymph  nodes,  giving  the  characteristic  rounded  appearance. 
The  displacement  of  the  auricular  lobule  with  the  lobe  of  the  ear  in 
the  center  of  the  swelling  assists  in  fixing  the  diagnosis. 

In  some  instances  there  is  little  or  no  discomfort,  and  the  child 
is  not  willing  to  go  to  bed.  After  seven  or  ten  days  the  swelling 
subsides  and  entirely  disappears.  Relapses,  however,  may  occur. 
Occasionally  the  swelling  is  very  large  and  painful.  In  exceptional 
instances  only,  the  submaxillary  glands  may  alone  be  involved. 

Lymphocytosis  is  quite  a  constant  symptom,  especially  at  puberty 
(Wile). 

I  Complications. — In  boys  orchitis  is  occasionally  seen,  and  the 
same  may  be  said  of  ovarian  pain  in  girls.  The  breasts  especially 
in  girls  may  be  tender.  When  these  complications  do  occur,  the 
child  is  generally  at  or  near  the  age  of  puberty.  The  lymph  nodes 
may  Ijecome  secondarily  involved,  and  suppuration  of  the  affected 
glands  take  place,  but  only  if  there  has  been  a  mixed  infection. 
Deafness,  inflammatory  eye  diseases  and  rarely  nephritis  are  com- 
plications Avhich  may  occur  and  should  be  guarded  against. 

Differential  Diagnosis. — Mumps  should  not  be  confounded  with 
hypertrophied  lymph  nodes  which  present  an  irregular  nodular  swell- 
ing and  are  not  found  on  the  face.  An  examination  of  the  throat  or  a 
concomitant  infectious  disease  may  account  for  such  a  swelling.  In- 
volvement of  the  submaxillary  glands  alone,  so-called  submaxillary 
mumps,  must,  however,  be  considered.  If  with  a  history  of  exposure 
there  is  a  large  soft  swelling  filling  up  the  space  between  the  angle  of 
the  jaw  and  the  mastoid  process,  and  it  lifts  forward  the  lobe  of  the 
ear,  the  diagnosis  is  quite  certain. 

Prognosis. — In  this  benign  disease,  which  is  rarely  complicated, 
fatalities  do  not  occur,  and  the  prognosis  is  most  favorable.  Deafness 
sometimes  results  and  rarely  following  an  orchitis  the  testicle  ceases  to 
develop. 

Treatment. — As  it  is  a  communicable  disease,  the  ciiildren  should 


THE  INFECTIOUS  DISEASES,  269 

be  isolated.  If  there  is  fever  and  discomfort,  a  laxative  is  given,  and 
the  child  is  put  to  bed.  Local  anodyne  applications  of  3  per  cent, 
ichthyol-lanolin  ointment,  or  warm  oil  of  hyoscyamus  are  applied. 
Often  a  hot-water  bag  is  found  to  be  very  agreeable.  Mouth-washes 
of  listerin  or  boric  acid  solution  should  be  used  frequently.  The 
bowels  should  be  kept  freely  opened,  and  a  liquid  or  soft  diet  ordered. 
Guaiacol  ointment  (5  to  10  per  cent.)  is  soothing  if  orchitis  is  present 
as  a  complication.  The  patient  may  mingle  with  other  children  after 
the  third  week. 

Typhoid  Fever. 

Typhoid  fever  is  a  specific  infectious  disease  due  to  the  t3'phoid 
bacillus. 

Etiology. — Infected  drinking-water,  infected  milk,  and  contact  with 
attendants  who  may  be  typhoid  bacilli  carriers  are  in  greater  part 
responsible  for  the  infection  in  children.  Irresponsible  children 
are  liable  to  drink  contaminated  water  in  any  place,  and  especially  when 
going  about  at  summer  resorts.  Infants  and  young  children  are 
more  liable  to  infection  when  they  are  placed  close  to  the  ground  or  are 
handled  and  fondled  b}-  many  adults.  Dishes,  thermometers,  or  even 
flies  may  carry  the  infective  agent.  The  fall  of  the  year  when  the 
children  return  from  the  country  always  shows  the  greatest  number  of 
cases.  The  disease  is  by  no  means  as  rare  in  infants  and  children  as 
was  formly  supposed.  The  Widal  reaction  has  revised  the  figures. 
About  6  per  cent,  of  the  cases  occur  under  two  years,  and  8  per  cent, 
under  five  years,  and  46  per  cent,  between  five  and  fifteen  j-ears. 
Typhoid  fever  may  be  transmitted  from  the  mother  to  the  fetus. 

Pathology. — As  differentiated  from  the  pathology  of  the  disease  in 
adults,  we  have  a  milder  ulceration  of  the  solitary  follicles  and  Peyer's 
patches;  and  when  examined  postmortem,  it  is  often  difficult  to  dis- 
tinguish the  ulceration  from  a  case  of  ileocolitis.  In  infants  there  may 
be  no  ulceration  whatever.  In  older  children,  especially  where  heal- 
ing has  taken  place,  the  "shaven  beard"  appearance  is  sometimes  seen 
due  to  pigmentation.  The  ulceration  rarely  penetrates  beyond  the 
submucosa.  This  pathologic  picture  is  in  distinct  relation  to  the 
milder  character  of  the  symptoms  as  met  with  in  children.  The 
mesenteric  lymph  nodes  in  the  ileocecal  region  are  enlarged.  The 
spleen  may  be  enlarged,  congested,  and  soft.  The  mucous  membrane 
of  the  bronchi  and  larynx  are  often  involved  in  varying  grades  of 
inflammation.  The  kidneys  quite  regularly  show  cloudy  swelling. 
The  heart  muscle  shows  mild  grades  of  myocardial  degeneration. 


270  DISEASES  OF  CHILDREN. 

Symptomatology. — The  prodromal  symptoms  are  so  irregular  and 
so  apt  to  be  influenced  by  some  one  prominent  symptom  or  symptom- 
complex  as  to  lead  the  examiner  astray. 

In  infants  the  mode  of  onset  is  quite  different  from  that  of  older 
children.  The  infant  has  an  initial  high  fever  which  becomes  irregular 
or  remittent,  and  subsequently  the  symptoms  resemble  a  gastro- 
enteric infection.  Convulsions  are  the  exception;  older  children 
who  are  able  to  describe  their  symptoms  complain  of  headache  and 
chilliness.  Malaise  and  vomiting  are  frequently  observed.  Delirium 
at  night,  when  the  fever  is  high,  is  seen  after  a  few  days.  Epistaxis  is 
the  exception.  Cerebral  symptoms  may  usher  in  the  disease.  A  cough 
is  often  present  quite  early  and  serves  to  obscure  the  diagnosis.  A 
careful  physical  examination  of  the  chest  by  a  process  of  exclusion 
may  point  the  way  to  an  early  diagnosis.  It  will  be  well  to  take  up 
the  symptoms  seriatim  to  give  a  picture  of  the  varied  manifestations 
of  the  disease",  and  these  will  be  described  in  the  order  of  their  early 
assistance  in  diagnosis. 

Roseola. — These  spots,  which  are  macules  fading  on  pressure  and 
distinctly  discrete,  are  observed  in  more  than  60  per  cent,  of  the  cases. 
The  eruption  is  seen  as  early  as  the  fourth  or  fifth  day,  and,  as  a  rule, 
is  widely  scattered.  The  abdomen,  chest,  and  back  may  each  show 
them.  We  have  seen  hemorrhagic  areas  on  the  abdomen,  toes,  and 
heels  in  severe  or  fatal  cases. 

Spleen. — As  a  rule,  the  younger  the  child  the  less  often  is  the  en- 
largement felt  early.  It  is  distinctly  palpable  in  the  second  week. 
The  splenic  enlargement  often  persists  after  convalescence  has  begun. 
There  may  be  a  relapse  without  an  enlargement  of  the  spleen. 

Mouth. — The  rather  characteristic  tongue  seen  in  adults  is  rarely 
observed  in  children,  and  it  clears  up  much  more  rapidly.  Sordes  on 
the  lips  are  common. 

The  Stools. — These  are  not  necessarily  of  the  pea-soup  variety; 
in  fact,  moderate  constipation  more  often  persists  throughout  the 
disease. 

The  Temperature. — The  temperature  curve  is  only  rarely  typical. 
During  the  first  week  there  is  a  gradual  rise  in  temperature  until  the 
maximum  point  is  reached.  The  fever  now  assumes  a  remittent  type, 
but  it  is  not  unusual  to  have  intermissions.  Cases  with  cerebral  symp- 
toms may  have  a  hyperpyrexia  for  days. 

The  temperature  curve  may  last  from  two  to  six  weeks;  occasion- 
ally in  protracted  cases  there  is  a  gradual  daily  rise;  but  we  feel  that 
this  fever  may  be  solely  due  to  the  asthenia  caused  by  a  low  diet. 
Complications  such  as  bronchitis,  pneumonia,  otitis,  or  even  constipa- 


THE  INFECTIOUS  DISEASES.  .  .  271 

tion  may  influence  the  course  of  the  pyrexia  causing  irregularities  in 
the  curve.  Relapses  produce  a  low-grade  temperature  after  a  period 
of  normal  or  almost  normal  temperature. 

Laboratory  Tests. — An  early  test  and  one  which  often  gives 
results  during  the  first  week  is  the  use  of  blood  cultures  made  from 
freshly  drawn  blood.  The  Widal  reaction  (seep.  51)  is  present  in  95 
per  cent,  of  the  typhoid  patients,  and  may  be  obtained  as  early  as  the 
end  of  the  first  week. 

The  urine  and  feces  contain  the  bacilli,  and  improved  laboratory 
methods  show  their  presence  in  20  to  50  per  cent,  of  the  cases.  The 
Ehrlich-Diazo  reaction  is  sometimes  present  before  the  Widal  reaction, 
and  when  obtained  is  confirmatory  evidence  of  the  disease,  but  not 
pathognomonic. 

The  Blood. — The  red  blood-cells  and  the  hemoglobin  diminish 
as  the  disease  progresses,  but  the  leukocytes  are  quite  uniformly  low 
from  the  beginning.  With  the  establishment  of  convalescence,  the 
differential  count  shows  an  increase  in  the  eosinophiles  and  mononu- 
clear lymphocytes  and  a  corresponding  decrease  in  the  polynuclear 
neutrophiles. 

Pulse. — The  relatively  slow  pulse  is  obtained  only  in  older 
children,  from  ten  to  fifteen  years.  Infants  and  young  children  not 
uncommonly  have  a  pulse  rate  as  high  as  150.  Irregularity  is  quite 
frequently  noted,  while  the  dicrotic  pulse  is  rare. 

Pain. — It  is  seldom  that  this  symptom  is  elicited  in  young  sub- 
jects. In  older  children  it  is  present  in  the  ileocecal  region  in  a  good 
number  of  cases,  and  usually  is  accompanied  by  tympanites  and 
probably  is  a  result  of  ulcerative  processes  in  the  agminate  glands  or 
Peyer's  patches. 

Hemorrhages. — It  is  rare  to  have  hemorrhages  in  children.  When 
they  occur  the  amount  is  usually  small  and  more  easily  controlled. 

The  Heart. — Depending  upon  the  amount  of  toxemia  we  have 
myocardial  changes  which  may  produce  systolic  murmurs. 

Treatment.  Prophylactic. — If  children  live  in  vicinities  having  a 
suspected  water  supply,  or  remove  to  such  a  locality,  precautions 
should  be  taken  to  boil  the  water  and  to  supply  an  absolutely  clean, 
uncontaminated  milk.  The  excreta  of  the  attendants  should  be 
examined  for  the  possibility  of  the  presence  of  the  bacilli,  especially 
if  there  has  been  a  history  of  previous  typhoid.  Weaning  or  a  wet- 
nurse  are  indicated  if  the  mother  herself  is  infected. 

Further  experimentation  may  prove  typhoid  vaccination  of 
value  in  institutions  or  in  epidemics.  Typhoid  precautions  should  be 
scrupulously  observed  even  in  suspected  cases.     The  feces,   urine, 


272  DISEASES  OF  CHILDREN. 

dishes,  and  clothing  being  disinfected  with  carbolic  acid  or  chlorinated 
lime  (as  given  on  page  312).  The  napkins  of  infants  should  be  made 
of  cheap  material  and  destroyed  by  burning. 

General  Treatment. — Careful,  capable  nursing  far  exceeds  the 
value  of  drugs  in  this  disease.  A  well-kept  chart  recording  the  varia- 
tions in  temperature,  pulse,  and  respirations,  every  three  or  four  hours, 
with  notes  upon  the  character  of  the  pulse  and  stools  is  of  great 
importance  to  the  physician. 

The  room  should  be  as  large  as  possible  and  one  that  can  be  well 
aired,  and  in  which  quiet  can  be  maintained.  Two  beds  so  as  to 
allow  ready  change  of  linen  and  position  are  preferable.  Scrupulous 
attention  should  be  paid  to  the  mouth,  tongue,  and  teeth,  keeping  them 
as  free  as  possible  from  foreign  material  by  the  use  of  swabs  dipped  in 
mild  antiseptic  solutions,  such  as  listerin  or  boracic  acid. 

For  disinfection  of  excreta,  see  section  on  Disinfectants  and 
Disinfection. 

Feeding. — In  mild  cases  in  which  the  temperature  is  not  high, 
and  the  digestive  processes  have  been  little  interfered  with,  milk 
and  lime-water,  thin  gruels,  plain  or  dextrinized,  broths  made  of 
mutton  or  chicken,  orangeade,  and  lemonade  form  a  list  which  will  not 
be  tiresome  and  which  furthermore  will  fairly  well  keep  up  the  patient's 
nutrition  until  he  is  able  to  take  semisolid  food  in  the  beginning  of 
convalescence. 

Severe  cases  with  continued  high  temperature  may  require  the 
peptonization  of  the  milk  or  the  discontinuance  of  milk  entirely,  if  it 
causes  tympanites.  Dextrinized  gruels,  beef  broths,  and  albumin 
water  may  be  substituted. 

In  convalescence,  in  addition  to  articles  already  permitted, 
zwieback  dipped  in  broths,  milk  toast,  junket,  scraped  beef,  baked 
custards,  and  soft-boiled  eggs  are  cautiousl}^  added  to  the  diet.  Mat- 
zoon  and  kumyss  or  home-prepared  buttermilk  are  occasionally  relished 
by  the  child  and  vary  the  monotony  of  his  restricted  dietary. 

Hydrotherapy. — The  fever  is  in  nearly  all  cases  effectively  con- 
trolled by  sponging  with  alcohol  and  tepid  water.  We  have  dis- 
continued the  use  of  tubbing.  Any  good  effects  of  the  reduction  of 
temperature  obtained  are  more  than  counterbalanced  by  the  nervous 
excitement  it  produces.  Therefore,  a  wet  pack  is  preferable  for  high 
temperatures  not  controlled  by  sponging,  the  sheets  being  wrung 
out  in  water  at  90°  F.  If  at  this  temperature  a  satisfactory  reduction 
is  not  obtained,  the  wrappings  may  be  sprinkled  with  water  at  85°  or 
even  80°  F.  An  ice-bag  may  be  applied  to  the  head,  especially  if 
there  is  headache  or  delirium,  but  it  requires  constant  vigilance  on 


THE  INFECTIOUS  DISEASES.  273 

the  part  of  the  nurse  who  should  be  instructed  to  remove  it  if  any 
cyanosis  develops. 

Drugs. — -With  the  exception  of  certain  symptoms  which  will 
require  control  by  the  use  of  medication,  no  drugs  should  be  given. 
Intestinal  antiseptics  and  alcohol  as  routine  measures  are  to  be 
deprecated.  The  bowels  are  kept  open  with  saline  enemas  which 
may  be  given  cool  if  the  temperature  is  high.  Divided  doses  of 
calomel  are  indicated  in  the  beginning  of  the  disease.  Tympanites 
should  be  prevented  rather  than  treated  by  careful  supervision  of 
offending  articles  of  diet,  especially  the  milk.  Headache  and  rest- 
lessness if  not  sufficiently  allayed  by  the  hydrotherapeutic  measures 
can  be  subdued  by  the  use  of  the  bromides.  Alcohol  is  given  in  the 
form  of  sherry  wine  or  whisky  if  the  pulse  is  weak  or  the  reaction  is 
not  good  following  a  pack.  Strychnia,  grains  ^^^,  tincture  of  digi- 
talis or  strophanthus,  in  two-minim  doses,  or  brandy  hypodermatically 
are  given  if  collapse  threatens.  If  hemorrhage  occurs,  a  light  ice 
bag  or  coil  is  immediately  applied  to  the  abdomen  and  Dover's 
powder  in  maximum  doses  given.  The  treatment  for  perforation 
which  would  be  evidenced  by  sudden  pain,  abdominal  tenderness,  and 
changes  in  the  rational  signs  demands  prompt  surgical  intervention. 


Influenza. 

{Acute  Catarrhal  Fever.     La  Grippe.) 

Definition. — -An  acute,  specific,  infectious  disease  affecting  the 
respii'atory  or  gastrointestinal  tracts,  and  usually  associated  with 
marked  prostration. 

Etiology. — While  the  disease  is  endemic,  especially  in  damp,  cold 
weather,  it  is  very  frequently  seen  in  epidemic  form.  The  immediate 
cause  is  a  small  bacillus  first  isolated  by  Pfeiffer  in  1892.  The  bacillus 
may  be  localized  in  the  mucous  membrane  of  the  nose,  throat,  or  lungs. 
Other  pyogenic  bacteria  may  be  present  with  the  influenza  bacillus, 
thus  giving  a  mixed  infection.  Pfeiffer's  bacillus  resembles  a  diplo- 
coccus,  having  rounded  extremities  and  staining  markedly  at  the  ends. 

Incubation. — From  twelve  hours  to  three  days. 

Pathology. — There  is  some  inflammation  in  nearly  all  the  mucous 
membranes.  In  addition  to  this,  complicating  inflammations  may 
exist  in  the  heart,  lungs,  middle  ear,  mastoid  process,  kidneys,  and 
gastrointestinal  tracts.  Meningitis  has  occasionally  been  reported 
as  caused  by  the  influenza  bacillus.  Tuberculosis  may  also  follow 
an  attack  of  influenza.  A  marked  general  depression  often  accom- 
18 


274  DISEASES  OF  CHILDREN. 

panying  influenza  is  doubtless  caused  by  the  toxins  secreted  by 
Pfeiffer's  bacillus. 

Symptomatology. — Although  young  infants  are  not  particularly 
susceptible  in  contracting  the  disease,  yet  when  they  are  attacked  it  is 
apt  to  assume  a  grave  form  with  high  temperature  and  great  prostra- 
tion. The  younger  the  child,  the  more  severe  is  usually  the  infection. 
In  older  children  the  average  clinical  description  of  symptoms  as  affect- 
ing principally  either  the  respiratory,  digestive,  or  nervous  systems 
will  hold  good.  It  is  true,  however,  that  these  varying  symptoms 
will  often  be  found  combined  in  a  given  case. 

Inflammatory  disturbances  of  the  respiratory  tract  predominate  in 
children.  There  is  marked  coryza  with  an  acrid  discharge  that  may 
excoriate  the  upper  lip.  A  general  pharyngitis  is  also  present,  the 
mucous  membrane  presenting  a  thickened,  spongy  appearance.  The 
tonsils  may  be  swollen  and  show  white  points  of  exudation  in  the 
crypts.  In  a  word,  there  is  a  severe  general  rhinopharyngitis  present 
that  is  prone  to  involve  the  Eustachian  tubes  and  middle  ear,  with  a 
secondary  enlargement  of  the  lymph  nodes  that  are  connected  with  this 
region  under  the  ear  and  back  of  the  jaw. 

These  disturbances  are  evidently  more  virulent  than  the  ordinary 
inflammation  met  with  in  this  region.  This  is  not  only  seen  locally, 
but  in  the  disposition  of  the  process  to  extend  downward.  In  some 
ways  this  is  analogous  to  the  course  of  measles.  The  larynx,  trachea, 
and  bronchi  are  quickly  involved,  but  in  many  cases  the  inflam- 
mation does  not  extend  below  the  larger  or  medium-sized  tubes. 
The  cough  may  assume  a  paroxysmal  character  simulating  pertussis. 
In  others  there  is  involvement  of  the  small  tubes  and  alveoli 
coming  on  soon  after  the  onset  of  the  disease.  This  type  of  broncho- 
pneumonia is  much  like  the  ordinary  form  as  far  as  physical  signs 
are  concerned,  but  early  prostration  is  more  marked  and  the  tem- 
perature is  usually  irregular  and  higher  than  the  local  lesion 
would  seem  to  warrant.  True  lobar  pneumonia  is  also  not  infre- 
quently seen,  and,  as  in  most  influenza  conditions,  exhibits  disturb- 
ances of  temperature  and  circulatory  and  nervous  depression  out  of 
proportion  to  what  would  be  expected  from  the  pulmonary  signs. 
Perhaps  the  most  frequent  exhibition  of  pneumonia  is  seen  in  the  form 
of  irregular  patches  with  sneaking  invasion,  when  it  is  very  difficult 
to  decide  the  exact  nature  of  the  pneumonic  process. 

Various  grades  of  pleurisy  are  frequent  accompaniments  of  pneu- 
monia, and  empyema  may  be  the  terminal  condition.  This  must  be 
constantly  borne  in  mind  as  this  empyema  is  even  more  insidious  than 
usual,  especially  in  infants. 


THE  INFECTIOUS  DISEASES.  275 

In  cases  where  the  gastrointestinal  symptoms  predominate  there 
may  be  severe  vomiting  and  the  passage  of  loose,  undigested  stools. 
Nourishment  is  badly  taken  and  after  an  interval  the  stools  may  con- 
tain mucus  and  even  blood.  The  gastroenteric  symptoms  may  ap- 
pear at  the  very  beginning  of  the  attack,  or  later  during  the  course  of 
the  disease.  While  under  proper  dietetic  and  medicinal  treatment 
these  symptoms  may  not  last  beyond  a  few  days,  they  naturally  add 
to  the  prostration,  and  in  young  and  feeble  infants  may  predispose 
to  a  fatal  ending. 

The  cases  in  which  pure  nervous  disturbances  preponderate  over 
the  inflammatory  symptoms  do  not  seem  to  be  so  common  in  early  life. 
Some  severe  cases  may  start  with  convulsions  and  simulate  meningitis 
with  photophobia,  stupor,  and,  in  older  children,  headache  and  deli- 
rium. In  uncomplicated  cases,  however,  these  marked  nervous  dis- 
turbances do  not  last  longer  than  a  few  days.  Cases  have  been 
reported  where  true  cerebral  meningitis  appears  to  have  been 
caused  by  the  influenza  bacillus.  The  writer  has  seen  a  number 
of  cases  of  plain  clinical  cerebrospinal  meningitis  where  the  fluid 
from  a  lumbar  puncture  showed  neither  the  meningococcus  nor  the 
pneumococcus.  It  is  possible  that  such  cases  are  due  to  the  influenza 
bacillus. 

Some  of  the  clinical  phenomena,  aside  from  the  types  just  men- 
tioned, may  be  noted.  The  fever  is  apt  to  be  irregular  and  at  times 
very  high,  especially  in  young  infants.  In  some  cases,  fever  and  pros- 
tration wall  be  the  principal  symptoms  of  the  disease  with  little  evi- 
dence of  any  local  inflammation.  In  other  cases,  an  irregular  fever 
may  last  for  several  weeks  and  simulate  typhoid  fever.  Here  all  the 
modern  diagnostic  methods  must  be  employed  in  order  to  make  a 
proper  diagnosis.  A  further  confusion  will  be  caused  by  intestinal  and 
diarrheal  symptoms  sometimes  accompanying  these  prolonged  cases. 
Some  of  the  protracted  cases  are  quickly  relieved  by  change  of  air, 
particularly  to  a  location  where  influenza  is  not  so  prevalent. 

The  skin  is  sometimes  involved,  with  various  forms  of  erythema. 
This  may  at  times  simulate  measles  or  appear  in  scarlet  form.  The 
irregular  character  and  distribution  of  the  eruption,  with  entire  ab- 
sence of  desquamation,  and  existing  in  connection  with  the  various 
symptoms  of  influenza  will  throw  light  on  its  character. 

The  urine  will  frequently  show  traces  of  albumin  in  influenza. 
It  is  probable  that  this  has  no  great  significance.  Cases  have  been 
reported  in  which  acute  nephritis  has  supervened.  Rachford  states 
that  if  nephritis  exists  as  part  of  the  influenza  attack  the  worse  symp- 
toms occur  early,  and   that   if  the  life  of  the  child   is  not  destroyed 


276  DISEASES  OF  CHILDREN. 

within  the  first  week  of  the  disease,  a  sure  and  steady  improvement 
begins  which  leads  to  complete  recovery. 

Diagnosis. — In  diagnosticating  this  disease,  the  bacteriological  aid 
is  not  so  great  in  practice  as  it  is  in  theory.  The  bacilli  are  difficult 
to  discover,  and  frequently  disappear  early  in  the  disease.  Not 
only  are  they  very  hard  to  find  in  smear,  but  their  culture  requires 
a  blood  serum  which  may  be  difficult  to  procure.  Accordingly,  in 
the  great  majority  of  cases,  the  physician  must  depend  entirely  on 
clinical  signs  for  a  diagnosis.  In  some  cases  he  has  to  rely  largely  on 
a  process  of  exclusion.  Wherever  an  illness  quickly  shows  a  prostration 
out  of  proportion  to  the  apparent  lesions,  influenza  may  be  expected. 
The  tendency  to  spread  through  a  family  is  suspicious,  as  the  disease 
is  highly  contagious.  This  will  be  helpful  in  children,  as  adults 
usually  contract  the  disease  first,  and  the  physician  on  being  informed 
of  this  will  be  helped  in  making  his  diagnosis.  There  are  nearly 
always  inflammatory  symptoms  in  the  nose  and  throat  to  help  the 
diagnosis.  The  onset  of  acute  tonsillitis  or  pneumonia  will  often  cause 
confusion.  The  former  usually  has  a  higher  temperature  and  a  more 
abrupt  onset,  while  the  latter  should  show  physical  signs  early  in  the 
attack.  A  central  pneumonia,  however,  may  require  several  days  for 
a  differentiation  from  influenza  where  both  are  suspected.  In  some 
cases,  the  course  of  the  disease,  with  presence  or  absence  of  local  lesions, 
will  be  all  that  will  clear  up  the  diagnosis. 

When  influenza  is  epidemic  probably  other  conditions  are  oftener 
explained  wrongly  as  due  to  this  cause  than  vice  versa.  At  any  rate, 
a  knowledge  of  its  prevalence  will  put  the  physician  constantly  on 
guard  in  examining  and  diagnosticating  obscure  sj'mptoms  accompanied 
by  prostration. 

Treatment. — The  first  thing  called  for  is  isolation  of  the  patient 
as  far  as  possible,  to  prevent  the  disease  spreading  through  the  family. 
The  room  should  be  well  ventilated  with  plenty  of  fresh  air,  as  this 
not  only  supports  the  patient,  but  tends  to  prevent  reinfection  as  well 
as  the  direct  spread  of  the  infection  to  others.  Close,  badly  ventilated 
rooms  often  seem  to  hold  the  infection  for  a  long  time.  The  child 
should  be  kept  quietly  in  bed,  even  in  mild  cases,  and  simple,  easily- 
digested  nourishment  given.  When  the  fever  is  high,  reliance  should 
be  placed  rather  on  frequent  spongings  with  cool  or  tepid  water  and 
alcohol  than  on  the  coal-tar  derivatives.  If  there  is  much  restlessness 
with  the  fever,  small  doses  (one  or  two  grains)  of  phenacetin  with 
citrate  of  caffein  may  be  given  for  a  few  doses  at  least.  Where  pain 
is  evident,  sulphate  of  codein,  gr.  ^-^  to  gr.  ^\,  for  an  infant  of  one 
year  may  be  administered  every  three  or  four  hours.     For  support 


THE  INFECTIOUS  DISEASES.  277 

and  stimulation,  sulphate  of  strychnin  is  most  valuable,  gr.  ^^-^  to 
gr.  -^^^  every  three  or  four  hours  for  an  infant  of  one  year.  From  ten 
to  twenty  drops  of  whisky  or  brandy  may  also  be  given  when  the 
pulse  is  weak.  The  bronchitis,  pneumonia,  or  gastroenteritis  are  to 
be  treated  as  when  occurring  as  primar}-  conditions  except  that  sup- 
port and  stimulation  must  be  specially  emphasized  on  account  of  the 
extra  depression  of  the  influenza.  When  the  attack  is  prolonged  or 
tending  to  constant  recurrence,  a  removal  to  another  section  of  the 
country  may  be  the  quickest  way  to  recovery.  Fumigation  of  apart- 
ments in  which  a  patient  has  been  long  sick  may  also  tend  to  prevent 
reinfection  or  the  spread  of  the  disease. 

Syphilis. 

Definition. — Syphilis  is  a  communicable  disease  that  may  be 
acquired  by  inheritance  or  by  direct  contact  after  birth.  In  the 
latter  case  there  is  always  an  initial  lesion,  the  chancre,  followed  by 
numerous  secondary  lesions,  affecting  principally  the  skin  and  mucous 
membranes,  and  by  tertiary  symptoms  involving  the  bones,  viscera, 
and  the  organs  of  the  special  senses.  In  hereditary  syphilis  there  is 
an  absence  of  the  initial  lesion  and  the  disease  shows  itself  in  the 
secondary  form  from  the  beginning. 

Etiology. — The  direct  cause  of  syphilis  is  now  generally  believed 
to  be  the  spirocheta  pallida.  In  1905  Schaudin  described  the 
spirochetae  in  syphilitic  conditions,  stating  that  this  germ  was  found 
constantly  in  smears  stained  by  the  Giemsa  method.-  There  is  some 
danger  of  confusing  the  spirocheta  with  connective  tissue  fibrils, 
nerve  endings,  or  elastic  tissue.  Buschke  and  Fischer  demonstrated 
the  silver  spirochetae  in  the  organs  of  infants  affected  with  congenital 
syphilis.  They  found  them  in  a  condyloma  and  in  the  liver  and 
spleen  of  two  cases  of  hereditary  syphilis,  and  likewise  in  the  kidneys 
and  skin  papules  of  another  case.  The  parasites  were  found  by  them 
to  be  attached  to  endothelial  cells  of  the  blood  vessels  and  they  could 
be  traced  from  the  vessels  into  the  surrounding  tissue. 

The  disease  will  here  be  considered  in  the  order  of  hereditary  or 
congenital  syphilis,  late  hereditarj^  syphilis  and  acquired  syphilis. 

Hereditary  or  Congenital  Syphilis. 

Definition. — This  is  a  form  of  the  disease  in  which  the  poison  is 
derived  from  the  father  or  mother  or  both,  as  it  is  lodged  in  the 
spermatozoa  of  the  male  or  the  ovum  of  the  female. 

Method  of  Transmission. — Probablv  the   disease  is   more   often 


278  DISEASES  OF  CHILDREN. 

transmitted  by  the  father  and  the  chances  of  this  depend  upon  certain 
factors,  such  as  the  stage  of  the  disease  and  the  degree  of  its  intensity, 
as  well  as  the  thoroughness  with  which  treatment  has  been  followed. 
There  is  danger  to  the  fetus  from  syphilitic  contagion  up  to  the 
fourth  year.  If  the  father  be  subjected  to  early  and  thorough  treat- 
ment, the  possibility  of  transmission  of  the  disease  will  be  much 
lessened,  and,  in  a  great  majority  of  cases  such  a  possibility  becomes 
lost  after  a  reasonable  lapse  of  time.  If  the  father  infect  the  mother, 
there  will  be  a  double  syphilization  of  the  offspring,  which  will  prob- 
ably be  still-born  or  soon  succumb  to  an  aggravated  form  of  the 
disease.  When  the  mother  is  suffering  from  acute  syphilis,  the 
disease  is  transmitted  in  an  active  stage  to  her  child.  The  degree  of 
such  transmission  depends,  as  in  the  case  of  the  father,  upon  the 
stage  and  severity  of  the  disease  and  the  nature  of  the  treatment 
employed.  During  periods  of  latency  the  mother  may  bear  healthy 
children,  followed  by  abortions  or  syphilitic  infants  caused  by  renewed 
manifestations  of  the  disease.  It  has  been  considered  that  the  power 
of  transmission  is  practically  lost  at  the  end  of  six  years.  In  some 
cases  the  mother  remains  apparently  uninfected  by  syphilis,  although 
the  fetus  may  have  been  infected  by  the  father.  This  immunity  was 
noted  in  1837  by  Colles  who  wrote  that  "a  new-born  child  affected 
with  inherited  syphilis,  even  although  it  may  have  symptoms  in  the 
mouth,  never  causes  ulceration  of  the  breast  which  it  sucks  if  it  be 
the  mother  who  suckles  it,  although  continuing  capable  of  infecting 
a  strange  nurse."  The  substantial  truth  of  this  dictum  remains 
unquestioned  and  is  known  as  Colles'  Law. 

Pathology. — The  fetus  may  die  any  time  during  uterogestation 
with  resulting  miscarriages,  or  may  live  to  term  and  then  be  still- 
born. When  born  alive,  the  lesions  resulting  from  the  disease  may  be 
broadly  divided  into  those  involving  the  skin  and  mucous  membranes, 
the  viscera,  and  the  bones.  There  may  be  erythema,  maculo-papules, 
or  papules  on  the  skin,  or  a  vesicular  and  pustular  eruption  may 
occasionally  be  seen.  Blebs  or  bullae  often  appear  at  birth  in  a 
severe  type  of  the  disease.  Crops  of  boils,  with  well-defined,  coppery- 
red  bases  are  apt  to  be  symmetrically  arranged  when  many  are  present, 
or  asymmetrically  distributed  if  only  a  few  are  seen.  The  lesions  of 
the  mucous  membranes  may  take  the  form  of  inflammatory  processes, 
of  mucous  patches,  or  of  superficial  or  deep  ulcerations.  The  junction 
of  skin  and  mucous  membrane  is  a  favorite  seat  for  the  syphilitic  lesion. 
The  viscera  are  more  apt  to  be  involved  in  hereditary  than  in  acquired 
syphilis,  the  lesion  taking  the  form  of  an  interstitial  hj'perplasia. 
The  growth  of  interstitial  connective  tissue,  which,  by  gradual  con- 


THE  INFECTIOUS  DISEASES.  279 

traction,  partially  obliterates  the  parenchyma  of  the  organ,  may 
involve  the  lungs,  spleen,  liver,  pancreas,  and  testicle.  Usually  a 
portion  of  a  lobe,  but  occasionally  a  whole  lobe  of  the  lung  may  present 
a  diffuse  fibroid  infiltration  with  a  grayish-white  color.  The  liver, 
which  is  not  infrequently  affected,  is  hardened  and  enlarged  from  a 
diffused  sclerosis,  although  occasionally  the  affection  may  be  cir- 
cumscribed. Gummata,  in  the  form  of  small,  circumscribed  nodules 
may  be  found  in  the  lung,  liver,  or  other  viscera.  Bone  lesions  are 
quite  common  and  some  that  were  formerly  referred  to  rickets  or 
scrofula  are  now  recognized  as  syphilitic.  There  are  two  principal 
ways  in  which  the  specific  poison  affects  the  bones  in  early  life.  In 
one  instance  the  brunt  of  the  disease  and  morbid  change  takes  place 
at  the  junction  of  the  shaft  with  the  epiphysis — osteochondritis; 
in  the  other,  the  periosteum  covering  the  long  bones  is  principally 
affected  with  a  resulting  periostitis.  Both  of  these  varieties  involve 
principally  the  long  bones.  Osteochondritis  develops  early  in  life, 
usually  within  the  first  month.  It  may,  however,  occur  later,  when 
it  is  not  apt  to  become  multiple,  and  may  be  unsymmetrical  in  dis- 
tribution. While  epiphyseal  swellings  may  be  due  to  rickets  as  well 
as  syphilis,  such  swellings  are  pretty  surely  syphilitic  if  they  occur 
during  the  first  six  months  of  life  and  they  are  relieved  by  mercurial 
treatment.  Again,  the  epiphyseal  swellings  of  rickets  are  always 
symmetrical,  while  those  of  syphilis  may  be  unilateral.  Periostitis 
occurs  later  in  hereditary  syphilis,  usually  after  the  child  has  begun 
to  walk.  It  attacks  by  preference  the  femur,  tibia,  and  bones  of  the 
forearm,  occurring  usually  from  the  second  to  the  fourth  or  fifth  year. 
At  an  early  stage  of  the  disease  the  bones  are  attacked  symmetrically, 
but  later,  circumscribed  nodes  may  be  placed  unilaterally. 

A  dactylitis  attacking  by  preference  the  proximal  phalanges  of 
the  metacarpal  and  metatarsal  bones,  enlarging  them  to  several  times 
their  natural  size,  may  occur.  There  is  not  much  destruction  of  bone 
but  after  a  time  the  skin  may  become  inflamed  and  break  down  from 
the  formation  of  an  abscess.  Craniotabes  may  result  from  the  mal- 
nutrition of  syphilis  as  well  as  from  rickets. 

Symptomatology. — The  symptoms  vary  greatly  in  severity  from 
cases  showing  good  nutrition  and  one  or  two  slight  lesions  only  to 
such  severe  infection  as  to  produce  early  death.  In  the  latter  case, 
the  fetus  may  be  attacked  in  the  uterus  resulting- in  abortion  more  or 
less  early  in  the  pregnancy.  As  the  disease  lessens  in  severity  in  one 
or  both  parents  the  pregnancies  will  be  longer  in  duration  and  finally 
an  apparently  healthy  infant  may  be  born.  While  there  may  be 
evidences  of  syphilis  at  birth,  the  onset  is  often  delayed  until  weeks 


280 


DISEASES  OF  CHILDREN. 


or  months  afterward.  In  the  majority  of  cases  the  primary  symp- 
toms will  be  noted  before  the  end  of  the  second  month.  The  earlier  the 
disease  manifests  itself  after  birth,  the  graver  will  be  the  nature  of 
the  attack.  Very  early  syphilis  is  usually  accompanied  by  emacia- 
tion, severe  coryza,  cracked  and  ulcerated  lips,  eruptions  of  bullae, 
particularly  upon  the  palms  of  the  hands  and  soles  of  the  feet,  and 
evidences  of  visceral  and  bony  disease.  In  the  older  cases  there 
may  be  no  apparent  interference  with  nutrition,  and  possibly  one  or 
two  muocus  patches  may  be  the  only  active  manifestation  of  the  disease. 
As  noted  in  the  pathology,  almost  any  structure  of  the  body  may  be 
involved  in  the  course  of  the  disease. 


Fig.  78. — Congenital  syphilis. 


The  skin  rashes  often  develop  rapidly  and  are  apt  to  be  less 
symmetrical  than  those  seen  in  adults;  they  are  likewise  polymorph- 
ous, as  several  different  forms  of  eruption  may  be  exhibited  at  the 
same  time  in  a  given  case.  There  may  be  first  an  eruption  of  small, 
round  pink  spots,  disappearing  on  pressure,  and  usually  appearing 
first  on  the  lower  portion  of  the  abdomen.  These  may  later  take 
on  a  coppery  discoloration.  A  papular  syphilid  may  be  seen  in  the 
form  of  small  or  large  flat  papules  which  are  not  so  apt  to  group 
themselves  into  lines  and  circles  as  in  older  subjects.  Neither  are 
they  so  solid  and  deeply  infiltrated  as  in  the  adult.  Upon  the  palms 
and  soles  these  papules  may  be  very  abundant  and  fuse  together, 
presenting    a    thickened,    dull-red    surface.     The   vesicular   syphilid 


THE  INFECTIOUS  DISEASES. 


281 


is  not  common;  the  vesicles  may  be  associated  with  pustules,  and 
appear  in  closely-arranged  groups  about  the  mouth  and  chin  or 
various  other  parts  of  the  body,  especially  the  nates  and  hypogas- 
trium.  Pustules  may  appear  on  the  face,  buttocks,  and  thighs.  Pem- 
phigus is  seen  only  in  the  severer  forms  of  the  disease  and  then  pref- 
erably on  the  palms  of  the  hands  and  soles  of  the  feet.  A  smoky 
discoloration  of  the  skin,  seen  most  distinctly  in  the  prominent  parts 
of  the  face,  such  as  the  eye-brows,  cheek-bones,  and  bridge  of  the  nose 
may  occasionally  be  the  only  manifestation  on  the  skin.  There  is  apt 
to  be  a  dryness  of  the  skin  which  may  hang  in  loose  folds  from  the 
general  cachexia. 


Fig.  79. — Condylomata  about  the  anus  in  syphilis. 


The  mucous  membranes  are  early  affected.  One  of  the  most 
typical  symptoms  is  the  coryza.  At  first  there  may  be  a  serous 
discharge  which  gradually  becomes  worse  until  the  nasal  secretion 
takes  on  a  purulent  or  even  a  bloody  character  with  excoriations 
of  the  upper  lip.  The  secretion  may  become  inspissated,  forming 
crusts,  which  may  completely  block  up  the  nasal  passage.  There  is 
often  flattening  of  the  bridge  of  the  nose  from  interference  with  respira- 
tion. Mucous  patches  are  oftenest  seen  in  the  mouth,  about  the  nose, 
upon  the  scrotum,  vulva,. labial  commissures,  and  occasionally  at  the 
umbilicus.  Deep  fissures  sometimes  form  at  the  corners  of  the  lips, 
even  extending  well  out  into  the  cheek.     There  may  be  enlargement  of 


282  DISEASES  OF  CHILDREN. 

the  epitrochlear,  cervical,  cervicomaxillary,  axillary,  and  inguinal 
lymph-glands  but  there  is  not  a  general  adenopathy.  Codylomata 
are  sometimes  found  about  the  anus   (Fig.  79). 

The  long  bones  should  be  carefully  examined  for  enlargement  and 
thickening  of  the  epiphyseal  and  distal  ends.  The  epiphysis  may  even 
be  separated  from  the  shaft,  when  crepitation  will  be  found  upon  care- 
ful handling.  Dactylitis  is  usually  confined  to  one  phalanx  which  will 
be  enlarged  to  double  its  normal  size,  but  there  is  not  apt  to  be  much 
involvement  of  the  soft  parts;  several  phalanges  are  sometimes 
attacked.  Onychia,  often  followed  by  ulceration  around  the  nail, 
is  occasionally  seen.  The  first  teeth  are  delayed,  poorly  developed, 
and  will  probably  undergo  early  decay. 

A  profound  anemia  is  sometimes  seen,  characterized  by  a  diminu- 
tion and  alteration  of  the  red  blood-corpuscles,  the  appearance  of 
megalocytes  and  microcytes  and  of  nucleated  erythrocytes.  There 
is  leukocytosis  which  may  become  extreme. 

There  may  be  sufficient  disturbance  of  nutrition  to  induce  an 
atrophy  of  all  the  structures  of  the  body,  the  infant  presenting  a 
weazened  appearance.  This  is  oftenest  seen  in  bottle  babies  and 
some  infants  that  are  nourished  on  the  breast  may  remain  plump 
and  well-nourished  throughout  the  course  of  the  disease  with  only  a 
few  mucous  patches  to  give  evidence  of  a  mild  infection. 

Diagnosis. — It  is  usually  easy  to  diagnosticate  the  disease  from 
some  of  the  pathological  or  clinical  manifestations  just  described.  In 
cases  of  marasmus,  if  there  has  been  no  chronic  indigestion,  partic- 
ularly if  the  infants  have  been  fed  on  the  breast,  syphilis  may  be  sus- 
pected. Chronic  coryza  is  suspicious  and  mucous  patches  will  make 
certain  a  diagnosis.  The  following  points  are  characteristic  of  syphi- 
litic lesions:  They  are  general  in  their  distribution,  but  ambulatory 
and  changing,  and  usually  present  a  reddish-brown  tint;  where  crusts 
form  they  are  fairly  thick,  with  a  tendency  to  accumulate  in  layers, 
and  when  cicatrices  form  they  are  smooth  and  long  surrounded  by  a 
pigmented  areola.  The  bony  lesions  of  syphilis,  tuberculosis  and  rickets 
may  be  confused.  Morrow  gives  the  following  points  of  differen- 
tiation between  syphilis  and  tuberculosis:  1.  Syphilis  exhibits  a 
marked  predilection  for  the  long  bones;  its  habitual  localization  is  in 
the  diaphysis,  and  almost  always  at  its  terminal  extremity.  Tuber- 
culosis is  almost  exclusively  situated  in  the  epiphyses,  rarely  affecting 
the  shaft.  2.  In  syphilis  there  is  a  marked  enlargement  of  the  bone 
by  more  or  less  voluminous  tumors  or  hyperostoses,  with  little  or  no 
involvement  of  the  soft  parts;  in  tuberculosis  the  tumefaction  is  due 
less  to  increase  in  the  size  of  the  bone  than  to  edematous  infiltration  of 


THE  INFECTIOUS  DISEASES. 


283 


the  soft  structures.  3.  In  syphilis  there  is  little  tendency  to  suppura- 
tion and  necrosis;  in  tuberculosis  the  pyogenic  tendency  is  marked. 
4.  In  syphilis,  osteocopic  pains,  with  tendency  to  nocturnal  exacer- 
bation are  a  pronounced  feature;  in  tuberculosis  the  pain  is  dull  and 
heavy,  not  aggravated  at  night.  5.  The  osseous  lesions  of  syphilis 
rarely  react  upon  the  general  system,  while  those  of  tuberculosis  often 
determine  a  marked  impairment  of  the  general  health. 


Fig.  80. — Syphilitic  dactylitis. 


In  differentiation  of  syphiHs  from  rickets,  epiphyseal  swellings 
under  six  months  are  very  apt  to  be  syphilitic.  In  syphilis  the  epiphy- 
seal swelling  may  be  unilateral,  but  it  is  always  symmetrical  in  rickets. 
In  doubtful  cases  the  swelUng  must  be  subjected  to  specific  treatment. 
It  is  well  to  remember,  however,  that  rickets  and  syphilis  may  coexist 
in  the  same  case. 


284  DISEASES  OF  CHILDREN. 

Prognosis. — The  earlier  the  symptoms  appear  after  birth,  the 
severer  will  be  the  type  and  the  worse  the  prognosis.  Breast-fed 
infants  have  a  much  better  chance  than  those  artificially  fed.  If  the 
digestion  remains  good  and  the  manifestations  of  the  disease  are  not 
severe,  complete  recovery  takes  place  and  the  infant  may  grow  up 
healthy  and.  strong.  The  average  prognosis,  however,  is  bad.  Kas- 
sowitz  states  that  one-third  of  all  syphilitic  children  die  before  birth, 
and  among  those  who  are  born  34  per  cent,  die  in  the  first  six  months  of 
life. 

Treatment. — Parents  who  exhibit  any  specific  symptoms  or  who 
have  had  syphilitic  children  should  be  subjected  to  specific  treatment 
in  the  hope  of  avoiding  infection  of  the  fetus.  Mercury  is  the  specific 
remedy  and  may  be  administered  to  the  infant  either  externally  or 
internally.  Daily  inunctions  of  mercurial  ointment,  mixed  with  from 
two  to  eight  times  its  quantity  of  vaseline  or  rose  ointment,  may  be 
employed.  A  lump  about  the  size  of  a  small  hickory  nut  may  be 
rubbed  on  the  inside  of  the  thighs  or  in  the  axillae,  the  parts  having 
previously  been  cleansed  with  soap  and  warm  water.  It  is  more  cleanly 
to  apply  five  drops  of  a  10  per  cent,  solution  of  oleate  of  mercury 
three  times  daily.  Internally,  mercury  with  chalk  is  one  of  the  best 
preparations  in  doses  of  one-fourth  to  one  grain  three  times  a  day. 
Calomel,  in  doses  of  -^-^  to  ^  grain,  three  times  daily,  will  have  a  more 
rapid  action  when  such  is  desired.  Or  bichlorid  of  mercury  ^tt  to  ^V 
grain  may  be  given.  If  the  latter  induce  intestinal  irritation,  a  men- 
struum, containing  bismuth  and  pepsin,  will  usually  allay  it.  When 
mercury  is  given  for  a  long  time  it  is  well  to  occasionallj^  change 
its  form,  although  in  syphilis  it  is  a  tonic,  acting  like  iron  in  anemia. 
The  nostrils  must  be  kept  clear,  using,  if  necessary,  some  bland  oil  like 
albolin.  Mucous  patches  and  excoriations  must  be  kept  clean  and 
dusted  with  calomel  and  bismuth,  equal  parts.  It  is  usually  necessary 
to  give  mercury  for  at  least  a  year,  with  occasional  intervals  of  tonic 
treatment.  In  visceral  lesions  and  where  the  bones  are  involved  and 
evidence  of  gumma  in  any  part  of  the  body  appears,  iodid  of  potas- 
sium, in  doses  of  one  to  five  grains,  will  be  indicated.  The  general 
care  and  feeding  is  most  important.  While  the  infant  should  not,  if 
possible,  be  taken  from  the  mother's  breast,  it  must  never  be  given  to 
a  wet-nurse. 

Late  Hereditary  Syphilis. 

This  form  of  sj^philis  comprises  those  cases  in  which  early  evi- 
dences of  the  disease  have  either  not  existed  or  have  been  in  such  slight 
form  as  to  have  been  overlooked.     Late  hereditary  syphilis  may  mani- 


THE  INFECTIOUS  DISEASES.  285 

fest  itself  either  in  certain  active  lesions  plainly  to  be  attributed  to 
this  condition  or  by  certain  developmental  defects  that  may  easily 
be  confused  with  tuberculosis  or  rickets. 

The  secondary  teeth  are  affected  in  a  way  that  has  been  consid- 
ered pathognomonic.  The  principal  change  is  noted  in  the  two 
superior  middle  incisors,  which  are  small,  peg-shaped  with  scooped-out 
grinding  edges,  and  placed  at  such  an  angle  that  the  cutting  borders, 


Fig.  81. — Hutchinson's  teeth.     {Dr.  FrauenthaVs  case.) 

tf  continued,  would  meet.  They  may  occasionally  be  deflected  out- 
ward, and  are  known  as  Hutchinson's  teeth  (Fig.  81).  Ulceration  of 
the  palate,  usually,  beginning  in  the  center,  may  take  place  and  be  fol- 
lowed by  caries  or  necrosis  of  the  bone.  There  may  be  simultaneous 
or  consecutive  deep  ulceration  of  the  soft  palate,  pharynx,  and  naso- 
pharynx at  any  time  previous  to  the  age  of  puberty.  Large,  indolent 
mucous  patches  may  exist  in  the  mouth,  and  there  may  be  ulceration 
about  the  lips  leaving  long  scars,  especially  at  the  commissures  of 
the  lips.  The  nasal  bones  may  become  necrotic  with  depression  of 
the  bridge  from  destruction  of  the  bony  arch. 


286  DISEASES  OF  CHILDREN. 

A  periostitis,  accompanied  by  a  thickening  on  the  surface  of  the 
bone,  may  involve  the  long  bones,  especially  the  tibia,  ulna,  radius, 
and  humerus.  The  lesion  may  be  multiple  and  symmetrical,  although 
occasionally  unilateral.  Gummata,  involving  the  bones  and  occasion- 
ally the  soft  tissues,  may  be  seen,  and,  in  the  latter  case,  may  break 
down  with  ulceration  and  leave  large  scars.  Interstitial  keratitis, 
without  much  congestion  of  the  conjunctiva,  is  not  infrequent,  and  is 
liable  to  be  followed  by  corneal  opacities;  although  primarily  attacking 
one  eye,  it  may  involve  the  other.  There  may  coexist  an  indolent 
iritis  without  the  usual  severe  pain  and  photophobia.  A  chronic  form 
of  otitis  may  be  followed  by  deafness.  Painless  enlargement  of  one 
or  both  testicles  may  be  caused  by  syphilis,  but  there  will  be  apt  to  be 
lesions  in  other  parts  of  the  body  to  aid  in  the  diagnosis  when  this 
occurs.  In  many  cases  all  the  evidence  of  syphilitic  taint  in  child- 
hood will  be  found  in  arrested  and  perverted  development.  As  an 
example,  the  testicles  at  puberty  may  be  about  the  size  seen  in  very 
early  childhood,  and  in  girls  in  absence  of  mammary  development, 
delayed  menstruation  and  a  non-appearance  of  hair  on  the  genital  and 
axillary  region  may  be  noted. 

Treatment. — The  treatment  of  the  later  forms  of  syphilis  must 
depend  on  the  activity  of  the  morbid  process.  Mercury  in  some  form 
should  be  exhibited  when  there  is  any  evidence  of  active  syphilitic 
disease.  lodid  of  potash  is  also  to  be  given  in  fair  doses,  three  to 
five  grains.  If  there  is  no  evidence  of  an  active  syphilitic  process, 
the  treatment  will  resolve  itself  into  improving  the  nutrition  of  the 
child  in  every  way.  Good  food,  tonics,  iron,  cod-liver  oil,  and  change 
of  air  when  possible  are  all  of  value  in  aiding  healthy  growth  and 
development  in  these  retarded  cases. 

Acquired  Syphilis. 

The  syphilis  detected  in  early  life,  although  usually  hereditary, 
is  not  necessarily  so,  but  may  be  acquired.  A  primary  sore  upon  the 
genital  tract  of  the  mother  can  possibly  infect  the  infant  during  birth. 
The  nurse  or  attendant  may  have  a  primary  lesion  upon  breast  or 
lips.  Much  more  common  will  be  infection  from  some  secondary 
lesion,  especially  a  mucous  patch  upon  the  mouth  or  lips.  There  are 
many  ways  in  which  the  blood  or  infective  secretions  of  a  S3''philitic 
patient  may  come  in  contact  with  a  solution  of  continuity  in  the  skin 
or  mucous  membranes  of  an  infant  or  child.  A  chancre  will  then 
appear  at  the  point  of  contact,  followed  in  due  time  by  the  later 
manifestations  of  the  disease.     Rarely,  in  older  children,  the  disease 


THE  INFECTIOUS  DISEASES.  287 

may  be  contracted  by  sexual  contact.  The  symptoms  and  treatment 
present  essentially  the  same  elements  as  in  adult  life,  and  hence  will 
not  be  considered  here.  The  acquired  disease  in  the  infant  or  young 
child  tends  to  be  milder  than  the  hereditar}^  form  in  its  symptoms  and 
less  apt  to  affect  seriously  the  general  health  and  development. 


Epidemic  Cerebrospinal  Meningitis. 

(Cerebrospinal  Fever.) 

This  form  of  meningitis  is  an  acute  infectious  disease  due  to  the 
diplococcus  intracellularis,  characterized  by  motor  and  sensory 
cerebral  and  spinal  symptoms. 

Etiology. — The  disease,  without  question,  has  its  specific  gerrn 
in  the  diplococcus  intracellularis  meningitidis,  first  fully  described  by 
Weichselbaum  in  1887. 

This  organism,  fortunately  of  low  resistance,  gains  access  to  the 
general  system  through  the  blood  or  through  some  local  determination 
in  the  nasopharynx,  ear,  or  eye,  and  in  those  with  depleted  vitality 
and  lowered  resisting  force  finds  suitable  soil  for  its  propagation. 
It  usually  occurs  in  epidemic  form,  although  occas'.onal  sporadic  cases 
are  seen  from  time  to  time,  especially  in  the  large  centers. 

.The  spring  of  the  year,  after  prolonged  confinement  to  ill-venti- 
lated and  superheated  apartments,  finds  the  greatest  number  of  pre- 
disposed individuals.  It  is  essentially  a  disease  of  the  young.  Our 
youngest  case  was  twelve  weeks  old,  although  Rotch,  of  Boston, 
reports  a  case  six  days  old.  The  second  year  claims  the  greatest 
number  of  victims. 

Pathology. — In  making  postmortem  examinations  of  those 
dying  with  the  disease,  we  find,  as  a  rule,  an  exudative  inflammation 
of  the  pia  arachnoid  of  the  brain  and  spinal  cord.  The  amount  of 
infiltration  found,  however,  often  does  not  correspond  to  the  gravity 
of  the  symptoms  observed  during  the  life  of  the  patient.  The  degree 
of  infiltration  varies  from  an  intense  hyperemia  to  a  fibrinoplastic 
seropurulent  or  purulent  exudate.  This  exudate  is  most  marked  at 
the  base  of  the  brain  and  along  the  fissure  of  Rolando  and  the  dorsal 
portion  of  the  cord.  In  the  ventricles  is  found  a  cloudy  or  opaque 
serum  and  in  a  few  cases  pure  pus.  The  effusion  in  the  subarachnoid 
space  (and  it  must  always  be  kept  in  mind  that  there  is  more  fluid  in 
the  subarachnoid  space  in  children  than  in  adults)  is  increased  in 
normal  amount.  Frequently  there  is  seen  a  parenchymatous  degen- 
eration of  the  kidneys,  degeneration  of  the  heart  muscle  and  the 


288  DISEASES  OF  CHILDREN. 

muscles  in  general.  There  will  also  be  found  in  a  number  of  cases 
multiple  abscesses,  septic  joints  and  ecchymoses  of  the  skin  as  a  result 
of  complicating  conditions. 

Symptomatology. — In  cerebrospinal  meningitis  the  symptoms 
vary  according  to  the  type  of  the  disease  present.  The  onset  is 
usually  sudden  and  abrupt.  The  malignant  types  are  seen  largely 
in  the  epidemics  only,  and  are  responsible  for  the  large  mortality 
record.  Headache,  vertigo,  vomiting,  and  high  fever  are  soon  followed 
by  coma  and  death. 

The  symptoms  in  the  sporadic  cases  will  vary  with  the  gravity 
of  the  local  lesion  and  the  intensity  of  the  toxemia.  This  history  of 
the  prodromal  period  may  be  of  material  assistance  in  establishing  the 
diagnosis;  there  is  malaise,  headache,  chills,  loss  of  appetite,  body 


Fig.  82. — Cerebrospinal  meningitis  with  marked  opisthotonos. 

pains,  and  some  rise  of  temperature.  Later  frontal  headache  is  com- 
plained of  and  succeeded  by  vomiting,  restlessness,  and  rapid  pulse. 
Herpes  on  the  lips  and  nose,  retraction  of  the  posterior  cervical  group 
of  muscles,  hyperesthesia  and  opisthotonos  are  observed.  The 
general  nuti'ition  suffers  severely  and  emaciation  is  steady  and  pro- 
gressive. Delirium,  stupor,  or  profound  coma  develop.  Convul- 
sions of  a  severe  type  (particularly  in  infants  and  younger  children) 
are  apt  to  occur  at  or  near  the  beginning  of  the  disease.  The  loss 
of  flesh  and  strength  is  rapid  and  marked.  Photophobia  and  irregu- 
larity of  the  pupils  with  loss  of  pupillary  light  reflex  and  nystagmus 
are  quite  regularly  present.  Neuroretinitis  is  found  on  ophthal- 
moscopic examination  of  the  fundus  in  some  cases.  The  respirations 
vary  with  the  stage  of  the  disease;  they  are  increased  when  the  fever 
is  high,  sighing  and  shallow  when  stupor  begins  and  are  irregular 
when  coma  develops.  The  blood  shows  a  leukocytosis  rarely  under 
25,000  to  the  cubic  millimeter.  The  temperature  curve  is  not  char- 
acteristic and  bears  no  relation  to  the  prognosis.     The  excursions  are 


THE  INFECTIOUS  DISEASES.  289 

wide  and  varied.  The  pulse  is  rapid  and  sometimes  irregular.  Ecchy- 
motic  spots  and  purpuric  areas  are  seen  in  some  of  the  fulminating 
cases,  but  a  roseola  or  an  erythema  is  more  apt  to  occur  in  the  sporadic 
cases. 

The  reflexes  will  help  to  establish  the  diagnosis,  but  must  be 
interpreted  wdth  caution.  The  tache  cerebrale  is  always  obtained, 
but  is  only  a  minor  confirmatory  sign.  The  Babinski  reflex,  or 
extension  of  the  great  toe  on  irritating  the  plantar  surface  of  the  foot, 
is  confirmatory,  but  valueless  in  children  under  two  years  of  age, 
although  negatively  it  may  be  of  assistance.  Kernig's,  sign,  which  is 
obtained  in  nearly  all  the  cases  at  some  stage  or  other,  is  also  present 
in  all  forms  of  cerebral  irritation. 

MacEwen's  sign,  or  the  hollow  note  elicited  by  percussion  over  the 
parietal  bone,  is  obtained  only  in  those  cases  in  which  fluid  has 
accumulated  in  accessive  quantity  in  the  ventricles.  The  rigidity  of 
the  neck  with  dilatation  of  the  pupils  when  attempts  are  made  to  flex 
the  neck  is  also  a  helpful  and  confirmatory  sign  of  meningitis. 

The  urine  in  the  course  of  the  disease  often  contains  albumin  and 
hyalin  casts,  the  result  of  toxic  substances  in  the  blood  stream. 
Loefler  and  Gourand,  of  France,  have  lately  called  attention  to  the 
fact  that  in  the  beginning  of  the  disease  large  amounts  of  urine  of  low 
specific  gravity  are  passed,  containing  a  high  percentage  of  urea. 
An  examination  of  the  blood  will  assist  in  making  a  differential 
diagnosis.  Leukocytosis,  principally  of  the  polymorphonuclear  cells, 
is  present,  while  the  mononuclear  elements  predominate  in  the  tuber- 
culous type  of  meningitis. 

Lumbar  Puncture. — Although  the  diagnosis  can  often  be  made 
from  the  clinical  phenomena  alone,  confirmation  and  temporary 
relief  from  intracranial  pressure  symptoms  are  afforded  by  lumbar 
puncture,  and  it  is  also  an  aid  in  establishing  the  diagnosis  and  prog- 
nosis. The  procedure  is  not  difficult,  and  if  performed  with  aseptic 
precautions  and  a  due  regard  for  the  anatomy,  is  productive  of  no 
harm.     The  technic  is  as  follows  (see  Fig.  16,  page  52) : 

Infants  in  whom  opisthotonos  has  not  yet  developed  may  be  placed 
over  a  pillow  at  the  end  of  a  table,  the  spine  and  outlying  soft  parts 
being  thus  put  on  the  stretch.  The  spine  may  be  entered  between  the 
third  and  fourth  lumbar  vertebrae.  This  space  is  found  by  an  imagi- 
nary line  drawn  across  the  iliac  crests  and  intersecting  the  spine.  In 
older  patients,  or  those  with  opisthotonos,  it  is  necessary  to  place  them 
on  their  side  and  enter  to  one  side  of  the  median  line.  The  needle  of 
an  ordinary  good-sized  aspirating  syringe  cannot  be  improved  upon 
for  the  procedure.  A  small  trochar  and  cannula  may  also  be  used  and 
19 


290  DISEASES  OF  CHILDREN. 

10  to  15  c.c.  (^  ounce)  should  be  withdrawn,  provided  the  fluid  flows 
freely,  as  this  amount  will  include  fluid  from  the  cranial  cavity  and 
lead  to  more  accurate  bacteriological  results.  It  is  not  wise  to  with- 
draw more  than  30  c.c.  or  an  ounce  at  a  sitting.  In  infants  with  an 
open  bulging  fontanel,  an  amount  can  be  withdrawn  which  will 
appreciably  depress  the  fontanel.  Dry  taps,  which  occasionally 
occur,  are  usually  the  result  of  imperfect  technic,  the  operator  either 
not  reaching  the  spinal  canal,  or  the  needle  becomes  obstructed 
with  blood.  If  the  exudative  processes  have  occluded  the  connection 
between  the  ventricles  of  the  brain  and  the  cerebral  and  spinal  sub- 
arachnoid spaces,  as  sometimes  occurs  in  well-advanced  cases,  the  open- 
ing may  be  partially  occluded  and  the  fluid  flow  very  sparingly.  In 
cerebrospinal  meningitis  the  fluid  obtained  is  generally  clouded  or 
turbid,  sometimes  it  is  purulent  or  again  varies  from  time  to  time. 
In  a  small  percentage  of  cases  it  is  quite  clear  throughout.  It  contains 
the  diplococcus  intracellularis,  and  in  some  aspirated  fluids  in  addition, 
staphylococci  and  streptococci  are  found.  Polynuclear  leukocytes 
predominate  and  contain  the  specific  organisms. 

Complications. — Those  which  may  be  attributed  more  directly 
to  the  disease  itself  are  those  of  the  eye,  the  ear,  the  brain,  and  the  joints. 
The  drum  frequently  is  infected  and  may  result  in  deafness  and  the 
labyrinth  is  apt  to  be  likewise  involved. 

Chronic  hydrocephalus  develops  in  a  number  of  cases  beginning 
either  during  the  acute  stage  or  in  convalescence.  They  are  usually 
mentally  deficient  or  idiotic. 

Rarely  an  arthritis  develops  in  one  or  more  joints. 

Differential  Diagnosis. — As  a  rule,  the  symptoms  are  typical  enough 
to  make  the  diagnosis  of  meningitis,  which  is  confirmed  and  further 
differentiated  by  lumbar  puncture.  The  sudden  onset,  the  headache, 
fever,  vomiting,  or  convulsions  in  the  face  of  an  epidemic  are  especially 
significant.  Meningitic  symptoms  in  typhoid  fever  with  rapid  onset 
are  often  confusing.  The  blood  examination  for  leukocytosis  and  the 
Widal  reaction  should  be  used  to  assist  in  the  differentiation.  Tuber- 
culous meningitis,  especially  in  infancy,  is  often  confused  with  spo- 
radic cases  of  cerebrospinal  meningitis,  and  indeed  the  pathological 
examination  of  the  spinal  fluid  may  in  some  cases  be  absolutely  necessary 
to  differentiate  them.  The  slow  onset  in  tuberculous  meningitis,  the 
low  leukocyte  count,  and  the  absence  of  hyperesthesia  are  distinctly 
helpful  points. 

Prognosis. — We  can  base  our  prognosis  on  the  following  facts: 
Sporadic  cases  have  a  greater  natural  tendency  to  recover}^  Initial 
symptoms  do  not,  as  a  rule,  indicate  the  subsequent  course.     Mixed 


THE  INFECTIOUS  DISEASES.  291 

infections  as  found  in  the  spinal  fiuid  indicate  a  general  septic  condi- 
tion and  an  unfavorable  prognosis.  The  younger  the  patient  the 
more  unfavorable  the  outcome.  Do  not  interpret  as  a  sign  of  restora- 
tion to  health  a  temporary  remission  with  return  of  consciousness 
from  coma. 

Widely  dilated,  rigid  pupils,  unvarying  coma  with  slow  pulse,  sub- 
normal temperature,  persistent  opisthotonos,  and  convulsions  are  signs 
tending  to  a  fatal  termination. 

Treatment. — The  germ  and  its  toxins  must  be  combated.  De- 
tailed study  of  the  portals  of  entry  of  the  nfecting  organism  has  thus 
far  failed  to  establish  much  that  is  new.  Care  of  the  nasopharynx 
as  insisted  upon  by  Jacobi  and  Caille  is  a  local  measure  productive  of 
much  good,  especially  in  the  crowded  centers.  School  inspection  and 
a  higher  standard  of  sanitary  regulations  in  every  district  will  do  much 
to  prevent  epidemics  of  this  disease. 

Serum  Treatment. — The  promising  results  that  have  been  obtained 
from  the  use  of  Flexner's  antimeningitis  serum  when  used  by  the  sub- 
dural method  warrant  its  use  in  cases  in  which  the  diplococcus  intra- 
cellularis  has  been  demonstrated.  If  the  bacteriological  test  is 
impracticable  or  would  be  unduly  delayed,  the  serum  injection  is 
advisable  in  those  cases  in  which  a  cloudy  fluid  is  withdrawn  by  lumbar 
puncture.  The  earlier  the  serum  is  injected  the  better  the  results. 
By  its  use  this  long  exhausting  disease  appears  sometimes  to  be 
shortened  and  serious  complications  prevented.  The  serum  is  injected 
through  the  same  needle  after  the  withdrawal  of  at  least  30  c.c.  of  spinal 
fluid.  The  serum  is  obtained  in  vials  containing  15  c.c.  each,  and  two 
of  these  vials  warmed  to  body  heat  are  slowly  injected  into  the  canal 
unless  undue  resistance  contraindicates.  The  injections  are  repeated 
daily  from  four  to  six  days,  during  which  time  smear  preparations  will 
give  information  as  to  the  effect  on  the  diplococci.  If  the  temperature 
drops  and  the  coma  is  lessened,  the  intervals  are  increased  and  the 
injections  are  repeated  only  when  any  aggravated  symptoms  return. 
In  infants  sometimes  not  more  than  15  to  20  c.c.  of  serum  can  be  in- 
jected, without  producing  pressure.  In  older  children,  on  the  other 
hand,  when  the  pressure  symptoms  are  intense  and  the  fluid  flows 
freely,  as  much  fluid  as  possible  should  be  allowed  to  escape  and  a  cor- 
responding amount  of  serum  injected. 

General  Treatment. — A  very  important  element  of  the  treatment 
is  conservation  of  the  patient's  strength  by  well-regulated  nourishment 
and  skillful  nursing.  Care  of  the  excretory  functions  and  relief  of 
pressure  symptoms  are  important  elements  of  the  treatment.  The 
patient  should  be  isolated  in  a  well-ventilated  quiet  room,  the  eyes 


292  DISEASES  OF  CHILDREN. 

shielded  from  the  light,  the  head  and  the  neck  being  raised  upon  a 
pillow  to  relieve  in  part  the  congestion  of  the  brain.  The  bowels 
are  kept  open  by  calomel  or  enemas.  The  diet  may  be  fluid  or  semi- 
fluid, of  a  stated  quantity,  and  careful  note  kept  of  the  amount  in- 
gested. Forced  feeding  should  be  resorted  to  if  necessary  by  gavage. 
Water  should  be  given  freely.  An  ice-bag  should  be  applied  inter- 
mittently to  the  head  if  the  temperature  rises  above  101°  to  102°  F. 
Warm  baths  at  115°  F.  for  twenty  minutes,  twice  a  day,  with  cold 
applications  to  the  head,  do  much  to  produce  comfort  and  allay  pain. 
While  in  the  bath  the  nasopharyngeal  toilet  can  be  made  with  normal 
saline  solution.  Colonic  irrigations  are  used  to  eliminate  the  toxins, 
promote  the  flow  of  urine,  and  to  stimulate  the  patient.  When  they 
are  given  at  a  temperature  of  80°  F.  they  also  control  the  higher  rises 
of  temperature. 

The  baths  will  also  prevent  in  great  measure  the  formation  of 
bed-sores,  and  the  necessary  change  of  position  will  be  beneficial  to 
the  pulmonary  circulation. 

For  the  relief  of  marked  restlessness  or  convulsions  bromids 
and  chloral  per  rectum  are  to  be  preferred  to  the  opiates.  Camphor 
in  sterile  olive  oil  hypodermatically  (one  grain  to  ten  minims)  is 
given  when  stimulation  is  necessary. 

Lumbar  Puncture:  This  procedure  will  be  indicated  for  (a) 
purposes  of  diagnosis;  (b)  in  infants  where  there  is  a  bulging  fontanel 
or  in  children  where  MacEwen's  sign  can  be  elicited,  and  in  any  case 
to  control  convulsions  or  sudden  onset  of  coma;  in  other  words,  symp- 
toms of  intracranial  pressure,  and  (c)  for  the  injection  of  the  anti- 
meningitic  serum. 

Anterior  Poliomyelitis. 

(Infantile  Paralysis.     Essential  Paralysis  of  Children. 
Acute  Atrophic  or  Wasting  Paralysis.) 

Definition. — An  acute  inflammatory  process  taking  place  in  the 
anterior  horns  of  the  spinal  cord,  accompanied  by  a  sudden  and  com- 
plete parah^sis  of  various  groups  of  voluntary  muscles,  followed  by  a 
rapid  wasting  of  the  affected  muscles. 

Etiology. — The  onset,  course,  and  symptoms  suggest  an  infectious 
nature,  but  no  microorganism  as  a  cause  of  the  disease  has  yet  been 
discovered.  The  nerve  centers  of  the  brain  and  spinal  cord,  the  fluid 
derived  from  lumbar  puncture,  and  the  blood  have  as  yet  been  searched 
in  vain  for  the  specific  cause.  Special  liability  to  the  disease  exists 
below  the  age  of  three  years,  fully  half  of  the  cases  occurring  during 


THE  INFECTIOUS  DISEASES.  293 

this  period.  This  is  likewise  the  period  of  dentition,  but  it  is  doubtful 
if  this  bears  any  causative  relation  to  the  disease.  Cases  occur  often- 
est  in  warm  weather  and  boys  are  attacked  oftener  than  girls.  Oc- 
casionally the  disease  comes  on  after  exposure  to  cold;  it  may  also  be 
seen  in  connection  with  certain  infectious  fevers,  such  as  scarlatina 
and  typhoid  fever.  The  relation  between  these  factors  and  the 
disease,  as  to  cause  and  effect,  is  somewhat  uncertain.  The  occurrence 
of  occasional  epidemics  confirms  the  theory  of  the  probable  specific 
infectious  nature  of  the  disease. 

Pathology. — The  inflammation  that  is  localized  in  the  anterior 
horns  of  the  spinal  cord  seems  to  be  induced  by  some  toxin  brought 
there  by  the  blood  current.  There  is  dilatation  and  proliferation 
of  the  endothelial  walls  of  the  blood-vessels  of  the  part  of  the  cord 
affected.  The  central  arteries  of  the  spinal  cord  are  intensely  con- 
gested followed  by  those  of  the  anterior  median  fissure.  As  the 
posterior  horns  are  chiefly  supplied  with  blood  from  the  peripheral 
arteries,  they  are  less  affected  when  the  inflammation  is  limited  to  the 
distribution  of  the  central  arteries.  After  engorgement  of  all  the 
arterial  twigs,  diapedesis  occurs  and  infiltration  of  the  tissue  by  small 
cells  and  serum.  According  to  Goldschreider,  it  is  this  choking  of  the 
gray  matter  by  the  inflammatory  products  that  leads  to  the  suspension 
of  functional  activity,  and  when,  as  in  many  cases,  from  impoverished 
nutrition  the  cells  of  the  anterior  horns  are  actually  disintegrated  by 
the  inflammatory  products,  permanent  destruction  of  the  nerve  tissue 
ensues.  The  ganglion  cells  soon  show  granular  degeneration  which 
may  be  followed  by  disintegration  and  atrophy.  The  cells  in  the 
anterior  horns  are  arranged  in  groups  having  definite  physiological 
motor  and  trophic  functions.  When  these  cell  groups  are  finally 
destroyed  and  replaced  by  connective  tissue,  the  parts  they  innervate 
will  likewise  undergo  degenerative  changes.  The  muscles  become 
atrophied,  and  their  fibrils  replaced  by  connective  or  adipose  tissue. 

Symptomatology. — The  invasion  is  usually  acute  with  evidences 
of  general  infection.  There  may  be  gastroenteric  or  nervous  dis- 
turbances with  fever.  The  disease  often  begins  with  vomiting,  and 
diarrhea  may  occasionally  ensue.  In  other  cases,  general  convulsions 
are  seen  at  the  beginning.  Very  rarely  stupor  or  coma  may  follow 
the  convulsions  and  last  for  a  day  or  so.  The  temperature  is  frequently 
high  at  first,  perhaps  reaching  104°  or  105°  F.;  in  other  cases  it  is 
sHght — not  more  than  100°  or  101°  F.  In  rare  instances  the  initial 
symptoms  may  be  so  mild  as  to  escape  attention  and  the  paralysis  is 
the  first  thing  noted.  In  the  majority  of  cases,  however,  some  initial 
symptoms,  more  or  less  marked,  will  last  from  one  to  four  days  before 


294 


DISEASES  OF  CHILDREN. 


paralysis  is  discovered.  Occasionally  pains  in  the  limbs  may  precede 
and  accompany  the  paralysis  for  a  time,  and  thus  simulate  periph- 
eral neuritis,  but  such  pains  do  not  last  long.  The  most  obscure  cases 
are  those  in  which  the  child  is  suddenly  found  to  be  unable  to  stand 
or  walk,  perhaps  after  being  taken  out  of  bed  in  the  morning.  The 
paralysis  is  absolute,  the  affected  part  being  completely  flaccid.  It 
develops  rapidly,  usually  reaching  its  full  extent  in  from  twenty-four 
to  forty-eight  hours;  in  rare  cases  it  may  be  slower  in  onset,  so  that  a 

week  or  even  longer  may  elapse  before 
it  appears  to  reach  its  maximum  extent. 
There  is  then  a  more  or  less  rapid  sub- 
sidence of  the  loss  of  power,  but  little 
change  is  to  be  noted  during  the  first 
three  or  four  weeks  after  the  beginning 
of  the  attack.  Most  of  the  improve- 
ment will  take  place  during  the  first 
three  months,  and  after  this  interval 
any  paralysis  remaining  will  usually  be 
permanent.  The  paralysis  most  often 
takes  the  form  of  monoplegia,  the  right 
leg  being  oftenest  affected.  The  left 
leg  and  the  right  or  left  arm  may  be- 
come involved  with  a  frequency  usually 
in  the  order  named.  In  severe  cases 
all  four  extremities  may  be  involved 
and  even  the  muscles  of  the  back  and 
neck  so  that  the  child  cannot  sit  erect 
or  hold  its  head  up.  In  very  rare  in- 
stances the  medulla  and  base  of  the 
brain  may  be  attacked,  as  well  as  the 
anterior  horns  of  the  cord,  forming  the  disease  called  by  Striimpell 
polioencephalitis.  The  cranial  nerves  may  then  become  affected  and 
the  patient  shows  signs  of  bulbar  paralysis  as  well.  These  severer 
types  are  more  apt  to  be  seen  when  the  disease  is  epidemic.  In  other 
rare  instances  there  may  be  hemiplegia  simulating  cerebral  paralysis. 
Paraplegia  is  rare.  Many  cases  will  only  show  a  paralysis  involving 
one  group  of  muscles,  as  the  peroneal  type.  As  the  motor  cells  in  the 
anterior  horns  are  arranged  in  groups,  the  muscles  involved  will  be 
found  to  have  a  coordinated  physiological  function.  The  limb  affected 
is  apt  to  be  cooler  than  the  other  parts,  and  an  atrophy  soon  affects  the 
paralyzed  muscles.  The  wasting  may  be  noticed  within  a  week  or  two, 
and   at   two   or   three   months   becomes   very   marked.     Eventually 


Fig   83. — Foot-drop  in  anterior 
poliomyelitis. 


THE  INFECTIOUS  DISEASES. 


295 


various  deformities  result  as  the  growth  of  bone  is  arrested  and  the 
whole  limb  becomes  smaller.  Where  only  one  or  two  groups  of  mus- 
cles are  affected  by  atrophy,  the  opposing  healthy  muscles  will  pro- 
duce other  deformties.  In  old  cases,  where  a  whole  limb  has  been 
affected,  there  will  be  various  grades  of  subluxation  from  a  relaxation 
of  the  muscles  and  hgaments  around  the  joints.  The  knee  and  shoulder 
are  particularly  apt  to  be  involved  in  this  way.  The  electrical  reaction 
of  muscles  and  nerves  may  prove  helpful  in  recognizing  the  disease. 
While  the  galvanic  and  faradic  responses  may  be  increased  in  the  first 
two  days,  there  is  soon  a  loss  of  response  to  the  faradic  current  with  a 
reaction  of  degeneration  to  the  galvanic  current  shown  by  the 
anodal  closure  contraction  being  greater  than  the  cathodal  closure 
contraction.  If  the  part  affected  responds  to  faradism  within  a  few 
weeks  it  will  probably  not  be  permanently  paralyzed. 

The  reflexes  are  lost  in  the  affected  muscles.  The  commonest 
example  of  this  is  seen  in  loss  of  the  knee-jerk.  Complete  recovery 
of  all  the  muscles  affected  is  extremely  rare,  although  the  permanent 
paralysis  may  be  limited  to  only  one  or  two  groups  of  muscles.  In 
very  rare  cases  death  may  take  place  during  the  early  course  of  the 
disease.     The  writer  has  known  this  to  occur  only  in  the  epidemic  form. 

Diagnosis. — It  is  impossible  to  make  a  positive  diagnosis  before 
the  onset  of  the  paralysis  as  the  first  symptoms  resemble  those  of  other 
acute  infections.  However,  an  absolute  paralysis  preceded  by 
vomiting,  fever  or  convulsions  points  to  a  spinal  origin.  In  a  few 
cases  there  may  be  early  cerebral  symptoms  simulating  cerebro- 
spinal meningitis,  but  paralysis  comes  later,  if  at  all,  in  the  latter  dis- 
ease, and  the  stiff  retracted  head  comes  early.  It  is  not  always  easy 
to  differentiate  a  palsy  as  cerebral,  spinal  or  peripheral.  The  follow- 
ing points  may  be  considered  as  helpful: 


Cerebral 
(or  motor  projection  fibers  in 
spinal  tracts) 


Peripheral 

(nerves) 


Onset  sudden,  with  convul- 
sions. 

Usually  affects  entire  limb 
and  incomplete.     Paresis. 


Onset  sudden,  with  fever 

Affect  muscular  ^oups; 
having  coordmated 
functions  and  not  sup- 
plied by  simply  onei 
nerve.  Total  paraly- 
sis (rule). 


Hemiplegia  (rule) Monoplegia  (rule)  leg 

Monoplegia  (rare)  arm Hemiplegia  (rare)  .    . 

Paraplegia  (very  rare) Paraplegia  (rare)    .    . 


Onset  gradual  (1  to  4 
weeks) . 

Affects  muscles  supplied 
by  one  nerve.  Total 
paralysis  (rule). 


I  Paralysis  symmetrical. 
Paraplegia  the  rule. 
Upper,    lower,  or    all 
four  extremities. 


296 


DISEASES  OF  CHILDREN. 


Cerebral 

(or  motor  projection  fibers  in 

spinal  tracts) 


Peripheral 

(nerves) 


Muscles  stiff  or  rigid 

Sensory  disturbance  usually 
absent.  If  present,  par- 
tial anesthesia 


No  atrophy,  or  late  from  dis- 
use. 

Deformity  early.     Athetosis. 


Growth  of  part  not  much  im- 
paired. 

Temperature    of    part    little 
affected. 

Increase  of  all  reflexes 

No  reaction  of  degeneration. 

Mind  often  affected.     Weak- 
ness or  epilepsy. 


Muscles  flaccid Muscles  flaccid. 

Sensation    not  affected ;    Association    of    sensory 
sometimes,  but  rarely        with  motor  paralysis. 


general     pains     very 
early  in  disease 


Early  and  rapid  atrophy 


Deformity  late. 


Growth  much  impaired. 


Numbness,  tingling, 
sensations  of  heat  or 
cold.  Limb  usually 
painful  along  course 
of  nerves  affected. 

Atrophy  rapid. 

Permanent  contractures 
rare. 

Growth  not  impaired. 


Some  coolness  in  affect- '  Slight  coolness  of  mus- 
ed limb.  cles  affected. 

Loss  of  reflexes Loss  of  reflexes. 

Always  reaction  of  de-  Usually  reaction  of  de- 
generation, generation. 


Mind  clear  and  no  men- 
tal sequelae. 


Mind  clear  and  no  men- 
tal sequela;. 


Prognosis. — A  more  or  less  rapid  lessening  in  the  extent  of  the 
paralysis  nearly  always  occurs  during  the  first  few  weeks  after  the 
beginning  of  the  attack.  There  will  be  little  or  no  improvement 
after  the  third  or  fourth  month.  The  prognosis  for  muscles  that 
waste  rapidly  is  poor.  A  reaction  to  the  faradic  current  is  a  sign 
of  beginning  improvement.  After  a  year  the  condition  will  be 
absolutely  stationary  as  far  as  the  paralysis  and  trophic  disturbances 
are  concerned.  Complete  recovery  is  exceedingly  rare,  and  is  more  apt 
to  be  seen  in  the  epidemic  form.  In  some  cases,  however,  so  few 
muscles  are  permanently  paralyzed  as  to  simulate  entire  recovery. 
The  prognosis  for  life  is  exceedingly  good,  although  a  few  will  occa- 
sionally die  early  in  the  attack  in  epidemics  of  the  disease  with  symp- 
toms of  severe  infection.  As  there  is  no  involvement  of  the  brain, 
the  mind  will  not  be  in  any  way  affected,  and  there  are  no  late  sequelae 
such  as  epilepsy. 

Treatment. — If  seen  early,  and  the  temperature  is  high,  ice-bags 
may  be  applied  to  the  spine.  When  this  is  discontinued,  stimulating 
embrocations  may  be  applied,  such  as  one  part  of  turpentine  in  two 


THE  INFECTIOUS   DISEASES.  297 

parts  of  camphorated  oil,  sprinkled  over  a  strip  of  flannel.  The 
bowels  should  be  kept  open  and  a  mild,  unstimulating  diet  given. 
Any  irritability  of  the  nervous  system  may  be  controlled  by  bromid 
of  sodium — from  three  to  five  grains,  every  three  or  four  hours. 
During  the  stage  of  active  congestion,  in  the  first  two  weeks,  from  five 
to  ten  minims  of  fluid  extract  of  ergot  every  four  hours  is  supposed 
by  many  to  have  some  effect  in  diminishing  spinal  congestion.  Abso- 
lute rest,  in  an  easy,  recumbent  position  is  very  important  during  the 
first  few  weeks.  No  effort  must  then  be  made  to  stimulate  the 
paralyzed  muscles,  and  the  parts  must,  if  necessary,  be  kept  in  a 
natural  position  by  straps  or  orthopedic  apparatus  to  prevent  early 
deformity  by  contractures.  It  is  especially  necessary  in  the  case  of 
drop-feet  to  raise  and  support  these  parts,  after  the  symptoms  of 
central  nerve  irritation  have  passed — usually  in  about  three  weeks; 
strychnin,  massage,  and  electricity  may  be  employed.  If  the  muscles 
do  not  respond  to  the  faradic  current,  galvanism  may  be  employed. 
The  late  deformities  of  the  disease  come  before  the  orthopedic  surgeon 
for  attempted  correction.  Tenotomy,  various  braces,  and  induced 
anchylosis  for  the  "flail-joints"  may  all  be  required. 

Epidemic  Paralysis  in  Children. 

The  occurrence  of  epidemics  of  paralysis  in  children  has  been 
reported  in  recent  years  by  a  number  of  observers.  They  have 
generally  been  considered  as  cases  of  anterior  poliomyelitis,  and  have 
natural  y  provoked  renewed  discussion  as  to  the  essential  cause  of 
this  disease.  The  prevailing  idea  among  recent  writers  appears  to  be 
that  the  spinal  paralysis  of  children  is  an  infectious  disease,  and 
occasional  epidemics  confirm  this  view.  The  abrupt  onset,  the  fever, 
the  gastric  disturbance,  occasional  attacks  of  convulsions  seen  both 
in  the  epidemic  and  endemic  forms  of  the  disease  point  to  its  infectious 
nature.  In  the  epidemic  form,  a  considerable  variation  from  the 
usual  type  of  the  disease  has  been  noticed,  some  cases  presenting  the 
symptom-complex  of  Landry's  paralysis,  the  infectious  nature  of 
which  is  known.  It  must  be  borne  in  mind,  however,  that  while  the 
microbic  nature  of  poliomyelitis  may  thus  by  analogy  be  assumed,  it 
has  not  yet  been  scientifically  demonstrated.  Medin  reported  an 
epidemic  during  the  summer  of  1887  in  Stockholm  with  some  fatal 
cases.  In  this  country  Dr.  Caverly  has  reported  an  epidemic  occurring 
in  the  summer  of  1894  in  Rutland,  Vermont.  One  hundred  and  thirty- 
two  cases  were  reported,  occurring  oftenest  in  strong,  healthy  chil- 
dren.    Many  of  the  cases  showed  marked  hyperesthesia  of  the  skin 


298  DISEASES  OF  CHILDREN. 

and  others  exhibited  muscular  rigidity  of  the  neck  or  back.  Eigh- 
teen of  the  cases  were  fatal,  usually  dying  early  in  the  attack.  A 
curious  feature  of  this  epidemic  was  that  domestic  animals  were 
affected  by  the  disease.  Horses,  dogs,  and  fowls  became  paralyzed, 
and  an  autopsy  on  a  horse  and  fowl  showed  the  lesions  of  polio- 
myelitis. This  epidemic  occurred  in  a  very  dry  season,  and  the  same 
thing  has  been  noted  in  most  other  epidemics. 

An  interesting  epidemic,  reported  by  Dr.  Chapin,  occurred  during 
the  summer  of  1889,  at  Poughkeepsie,  N.  Y.,  most  of  the  cases  being 
attacked  between  the  middle  of  July  and  the  middle  of  August.  A 
peculiarity  of  this  epidemic  appeared  to  be  the  existence  of  severe 
pain  in  the  parts  affected  by  the  paralysis.  A  number  of  the  cases 
carefully  examined  showed  absolute  paralysis  of  the  limbs  affected, 
with  loss  of  reflexes  and  apparently  considerable  pain  on  handling 
the  part.  There  was  such  marked  evidence  of  the  action  of  some 
infectious  principle  that  examinations  of  the  blood  from  three  cases 
were  made  by  Dr.  H.  T.  Brooks.  These  failed  to  give  any  positive 
results,  although  the  specimens  did  show  occasional  minute  micro- 
organisms (a  diplococcus)  to  which,  however,  no  etiological  significance 
was  attached  because  of  the  small  number  of  specimens  and  also 
because  the  latter  may  have  been  contaminated  from  the  skin  or  other 
source. 

The  prominent  feature  of  pain  and  its  more  or  less  persistence  in 
the  affected  limbs,  brought  up  the  question  of  neuritis.  One  of  the 
cases  proving  fatal,  a  careful  autopsy  was  made,  and  the  nature  of  the 
disease  in  this  particular  case  was  proven  to  be  poliomyelitis.  It 
seemed  that  while  this  epidemic  was  apparently  of  an  infectious  nature, 
in  some  cases  the  infecting  principle  attacked  the  anterior  horn  of  the 
spinal  cord,  in  others  the  peripheral  nerves,  and  that  possibly,  in  a 
few  cases,  both  parts  were  attacked.  Some  of  the  cases  were  reported 
by  the  physicians,  in  attendance  to  have  made  complete  recoveries 
in  from  one  to  four  months.  In  both  the  Stockholm  and  Rutland 
epidemics,  polioneuritis  was  reported  to  exist  in  some  of  the  cases  with 
poliomyelitis. 

During  the  summer  of  1907  an  epidemic  of  considerable  propor- 
tion existed  in  New  York  and  the  surrounding  country.  In  this 
epidemic,  pain  in  the  extremities  formed  a  marked  feature,  and  in  some 
cases  marked  cerebral  symptoms  were  noted.  Many  of  the  cases 
showed  great  gastroenteric  irritation  at  the  onset  of  the  disease. 
Occasionally  headache  and  rigidity  of  the  neck  simulated  cerebro- 
spinal meningitis.  A  few  cases  were  reported  n  which  symptoms  of 
bulbar  involvement  occurred.     A  number  of  deaths  were  also  reported 


THE  INFECTIOUS  DISEASES.  299 

during  this  epidemic,  the  fatalities  occurring  early  in  the  disease. 
It  is  believed  that  the  following  points  will  fairly  represent  the  peculiar- 
ities of  the  epidemic  form  of  paralysis  in  children: 

1.  The  disease  is  occasionally  fatal,  especially  early  in  the  attack. 
The  endemic  form  is  rarely,  if  ever,  fatal  in  its  ending. 

2.  There  are  great  variations  in  the  extent  of  the  paralysis  in 
the  epidemic  form.  Many  cases  show  very  extensive  palsy,  involving 
all  the  extremities  and  the  muscles  of  the  back  and  neck  as  well. 
Other  cases  show  a  very  slight  loss  of  power,  and  the  disease  is  doubt- 
less occasionally  overlooked  from  this  cause. 

3.  Pain  seems  to  occupy  a  more  prominent  feature  in  the  epidemic 
than  in  the  endemic  form.  This  pain  may  even  last  well  along  in  the 
course  of  the  disease.  In  the  ordinary  endemic  disease  if  pain  exists, 
it  is  not  apt  to  last  more  than  a  day  or  so. 

4.  A  certain  proportion  of  cases  in  these  epidemics  seem  to  un- 
dergo a  complete  recovery.  This  rarely,  if  ever,  happens  in  the 
endemic  form. 

5.  The  lesion  tends  to  be  more  varied  and  extensive  in  the  epi- 
demic than  in  the  endemic  form.  It  may  include  the  following  con- 
ditions: Polioencephalitis  of  Striimpell;  poliomyelitis;  peripheral 
neuritis,  and  occasionally  meningitis. 

Acute  Articular  Rheumatism. 

(Rheumatic  Fever.) 

Acute  articular  rheumatism  is  a  febrile  disease  of  the  joints 
characterized  by  transitory  inflammatory  attacks  which  do  not  tend 
to  suppuration. 

Etiology. — The  infectious  origin  of  the  disease  is  accepted  as  a 
fact;  although  the  direct  etiological  factor  is  still  in  dispute.  The 
disease  assumes  certain  characteristics  in  childhood  which  distinguish 
it  from  the  adult  type.  The  course  is  milder  and  shorter,  while  involve- 
ment of  the  heart  is  more  frequent  than  in  adults. 

Single  epidemics  and  a  succession  of  epidemics  have  been  reported 
from  time  to  time.  Several  members  of  the  same  family  may  be 
attacked  simultaneously. 

The  oral  cavity  and  more  particularly  the  tonsils  have  been  re- 
garded by  many  as  the  portal  of  entry  of  the  infecting  organism. 
Predisposing  factors  are  exposure  and  residence  in  cold  damp  apart- 
ments. Heredity  seems  to  play  a  distinct  part  if  the  predisposing 
factors  are  present. 

The  disease  is  not  very  common  before  the  fifth  year,  although 


300  DISEASES  OF  CHILDREN. 

cases  have  been  recorded  during  the  nursing  period.     One  attack  pre- 
disposes to  subsequent  attacks. 

Among  the  76  cases  studied  clinically  by  Chapin  the  following 
were  the  ages: 


6  mos. 

,  1 

9  yrs., 

9 

11  mos. 

,1 

10  yrs.. 

5 

20  mos. 

,1 

11  yrs., 

,  8 

3  yrs., 

1 

12  yrs.. 

7 

4  yrs., 

2 

13  yrs., 

9 

5  yrs.. 

4 

14  yrs., 

,  4 

6  yrs., 

6 

15  yrs. 

,2 

7  yrs.. 

3 

17  yrs.; 

,2 

8  yrs.. 

11 

Symptomatology. — An  attack  may  be  preceded  by  languor,  loss  of 
appetite,  mild  tonsillitis,  abdominal  pains,  and  indefinite  pains  in  the 
joints.  With  the  localized  pain  there  is  a  febrile  reaction  of  variable 
intensity,  102-104°  F.,  and  occasionally  there  is  vomiting.  The  knee- 
and  ankle-joints  are,  as  in  adults,  most  frequently  involved.  In  chil- 
dren the  hip  and  cervical  vertebrae  and  joints  of  the  fingers  and  toes  may 
be  the  areas  attacked.  Usually  more  than  one  joint  is  affected,  but 
symmetrical  involvement  is  not  the  rule.  It  is  exceptional  for  the 
attack  to  persist  more  than  a  few  days  in  any  one  joint.  The  joints, 
as  a  rule,  are  not  exquisitely  painful  on  active  or  passive  motion,  while 
the  swelling,  if  any,  is  moderate.  The  fascia  covering  muscles  may  be 
attacked  without  any  involvement  of  the  joints.  The  sternocleido- 
mastoid muscle  is  especially  liable  to  such  attack.  The  acid  perspira- 
tion so  commonly  observed  in  adults  is  rarely  present  in  children  A 
waxy  appearance  is  observed  in  severe  cases  with  insomnia,  anorexia, 
and  insatiable  thirst. 

The  blood  findings  are  of  no  assistance  in  making  the  diagnosis. 
Mild,  almost  afebrile  cases  may,  however,  be  followed  by  serious  in- 
volvement of  the  heart. 

Complications. — These  bear  a  direct  relation  to  the  toxins  of  the 
disease  itself.  Rheumatism  in  childhood  is  characterized  by  its 
cardiac  complications;  it  thus  must  always  be  considered  as  a  dis- 
ease of  serious  import.  Nearly  half  of  all  the  cases  leave  permanent 
cardiac  effects. 

The  mitral  valve  is  most  frequently  affected.  The  involvement 
is  accompanied  by  irregular  rises  of  temperature  and  increased  pulse 
rate.  The  symptoms  accompanying  valvular  defects,  however,  may 
be  the  first  indication  for  medical  attention  and  lead  to  the  discoverv  of 


THE  INFECTIOUS  DISEASES.  301 

their  rheumatic  origin.  Pericarditis  is  present  in  10  to  20  per  cent, 
of  all  cases  in  children  and  is  frequently  associated  with  endocarditis, 
and  is  an  important  and  often  fatal  complication.  Serous,  or  sero- 
fibrous pleurisy,  is  a  complication  seen  in  severe  and  long-standing 
cases.  Pneumonia  and  occasionally  nephritis  are  rarer  complications, 
in  all  probability  due  to  mixed  infection.  A  purpuric  rash  or  an 
erethema  may  be  seen  as  rheumatic  manifestations.  Chorea  must  be 
regarded  as  a  distinct  rheumatic  manifestation  and  often  may  precede 
the  disease.  Involvement  of  the  endocardium  is  not  rare  in  cases  of 
chorea.  Rheumatic  iritis  is  rare  in  childhood,  but  can  be  diagnosti- 
cated by  a  competent  opthalmologist. 

Rheumatic  nodules  occasionally  appear  under  the  skin  developing 
rapidly.  They  appear,  as  a  rule,  near  the  joints,  and  follow  the  course 
of  the  tendons.  Sometimes  they  are  painful  on  pressure.  They 
may  be  from  one  to  fifty  in  number,  and  may  last  for  several  weeks 
before  absorption  takes  place. 

Prognosis.— Rheumatic  polyarthritis  in  children  tends  to  quick 
recovery.  Relapses  are  common,  and  it  is  in  these  secondary  attacks 
that  the  endocardium  most  often  suffers.  Fatalities  may  follow  severe 
complications. 

Differential  Diagnosis. — Septic  arthritis  as  seen  in  scarlet  fever 
and  gonorrheal  arthritis  should  be  excluded,  as  should  the  rarer  cases 
of  pneumococcic  arthritis.  The  history  and  the  intense  localization 
tending  toward  suppuration  in  the  septic  types  will  assist  in  making  the 
diagnosis.  A  blood  count  in  septic  cases  will  show  high  leukocytosis. 
An  exploratory  puncture  is  often  justifiable  in  establishing  a  prompt 
diagnosis. 

Scarlatinal  polyarthritides,  as  a  rule,  affect  the  wrist-joints  first, 
then  the  shoulders,  knees,  and  feet.  They  appear  in  the  second  or 
third  week  of  the  disease,  and  last  about  one  week  unless  suppuration 
sets  in. 

Pneumococcic  arthritis  is  seen  usually  in  the  first  and  second 
years  of  life  as  a  sequel  of  a  bronchopneumonia,  or  a  lobar  pneumonia. 
The  pus  contains  diplococci  which  stain  by  the  Gram  method.  As 
a  rule  the  affection  is  limited  to  one  joint. 

Gonorrheal  arthritis  is  rare  in  children,  although  often  decidedly 
puzzling  from  a  diagnostic  standpoint,  unless  evidences  of  a  previous 
gonorrheal  infection  are  obtained.  It  appears  some  weeks  following 
the  local  attack.  The  knee-joints  are  as  a  rule,  primarily  involved, 
but  in  children  it  is  very  apt  to  be  polyarticular.  The  articulations 
are  extremely  painful,  there  is  a  high  irregular  temperature  and  the 
effusion  in  the  joints  contains  typical  gonococci. 


302 


DISEASES  OF  CHILDREN. 


Syphilitic  arthritis  is  symmetrical,  and  other  evidences  of  the  dis- 
ease may  be  present. 

Cases  of  epidemic  poliomyelitis  which  complain  of  intense  pain 
have  been  mistaken  for  rheumatism.  The  loss  of  the  patellar  reflexes 
and  the  electrical  reaction  will  serve  to  distinguish  them. 

Scurvy  in  infancy  may  occa- 
sionally be  mistaken  for  rheumatic 
polyarthritis.  The  history,  exami- 
nation of  the  gums,  of  the  urine,  the 
localization,  and  the  X-rays  will 
prevent  a  mistake  in  diagnosis. 

Treatment.  Prophylactic. — ■ 
Children  predisposed  to  rheumatic 
fever  or  who  have  had  an  attack 
of  rheumatic  fever  or  chorea  should 
avoid  exposure  to  dampness  or 
cold.  The  tonsils,  if  hypertrophied, 
should  be  removed.  The  diet  must 
be  carefully  regulated  and  all  forms 
of  intestinal  fermentation  promptly 
treated. 

Management. — Rest  in  bed 
should  be  considered  as  the  first 
and  most  important  direction,  and 
the  patient  should  be  kept  in  bed 
until  all  rheumatic  manifestations 
have  ceased.  Wearing  of  woolen 
or  merino  undergarments  is  to  be 
recommended. 

The  diet  may  consist  of  milk, 

broths,  paps,  bread,  and  lemonade 

for  the  thirst.     When  the  fever  has 

passed,  vegetables,  eggs,  and  finally 

meats  are  allowed. 

Drugs. — The  salicylates  in  the  form  of  the  sodium  salts  or,  better 

still,  novaspirin  are  effective  remedies  to  control  the  attacks.     Rest 

in  bed  and  the  early  exhibition  of  the  salicylates  are  the  only  weapons 

against  the  cardiac  complications. 

Novaspirin  in  doses  of  2  to  5  grains  three  to  four  times  daily 
to  a  five-year-old  child  should  be  persisted  in  for  a  week  or  more. 

Salol,  aspirin,  phenacetin,  salipirin,  and  salophen  (see  Dosage, 
page  64)  may  be  substituted  if  the  above  remedies  are  not  effective. 


Fig.  84. — Gonorrheal  arthritis,  com- 
plicating gonorrheal  vulvo-vaginitis. 
Polyarticular  in  distribution. 


THE  INFECTIOUS  DISEASES. 


303 


The  tincture  of  the  chlorid  of  iron,  five  drops  in  water  after  meals 
in  convalescence  is  beneficial.  However,  if  the  diagnosis  be  correct, 
aspirin  or  sodium  salicylate  will  give  speedy  relief.  The  joints  should 
be  enveloped  in  cotton  wool.  Immobilization  w^th  splints,  especially 
with  restless  children,  will  often  give  considerable  relief.  An  ice-bag 
is  applied  over  the  heart  for  an  unduly  rapid  pulse  or  endocardial 
involvement. 


Fig.  85.— Infectious  arthritis.     [Dr    MacKenzie's  case.) 


Infectious  Arthritides. 

Following  any  of  the  acute  infectious  diseases,  especially  pneu- 
monia, scarlatina  and  typhoid  fever,  there  may  result  an  active 
inflammation  in  the  joints  or  neighboring  bony  structures.  These 
arthritides  result  from  bacterial  invasion  in  some  instances,  and  in 
others  are  apparently  the  result  of  the  toxic  products  of  the  under- 
lying disease.  Suppuration  may  occur,  as  evidenced  by  fluctuation 
and  tenderness.  Aspiration  is  then  indicated  and,  besides  relieving 
the  joint,  assists  in  establishing  the  diagnosis  from  a  bacteriological 
standpoint.     These   cases   do  not  react  to  the  salicjdates  or  their 


304 


DISEASES  OF  CHILDREN. 


derivatives,  and  are  to  be  distinguished  by  the  greater  degree  and 
rapidity  of  the  involvement  and  the  tendency  to  suppuration.  The 
temperature  often  assumes  the  wide  variations  seen  in  sepsis  of  any 
part  of  the  body. 

Rheumatoids. 


Formerly  these  affections  were  classed  under  the  head  of  chronic 
articular  rheumatism,  and  much  confusion  has  resulted  from  attempts 

to  classify  them  as  following  or 
developing  from  rheumatic  fever. 
One  group  of  these  cases 
often  designated  as  villous  ar- 
thritis results  from  thickening  of 
the  synovial  sheath  and  an  over- 
growth of  the  villi  within  the 
joint.  This  affection  may  be 
mono-  or  polyarticular,  and 
spreads,  if  at  all,  only  slowly 
from  joint  to  joint.  As  a  rule 
there  is  no  fever,  the  joints 
assuming  a  swollen,  waxy,  shin- 
ing appearance.  In  cases  of 
long  standing  the  joints  become 
more  or  less  ankylosed  and 
deformities  result. 

Arthritis  deformans 
sometimes  occurs  before  puberty, 
but  it  is  rare.  The  characteristic 
features  are  joint  deformity, 
pain,  and  disability.  The 
disease  affects  many  joints  at 
one  time  and  progressively  in- 
volves others.  The  joints  of  the  fingers  are,  as  a  rule,  the  first  to 
be  affected.  Later  there  is  seen  much  atrophy  of  the  soft  parts 
and  even  of  the  bones  themselves.  These  chronic  forms  must  be 
differentiated  from  tuberculous  and  syphilitic  arthritides.  Sj^philitic 
affections  usually  appear  late  in  neglected  cases  and  fortunatel}  are 
rarely  seen  in  children.  There  is  an  effusion  of  serofibrinous  fluid 
into  the  joint  accompanied  by  little  or  no  constitutional  symptoms. 
The  history,  and  sometimes  a  specific  inflammation  of  the  cornea  may 
definitely  determine  the  diagnosis. 


Fig.  86. 


•Arthritis  deformans  in  an  eight- 
year-old  girl. 


THE  INFECTIOUS  DISEASES.  305 

Tuberculous  arthritis  is  accompanied  by  bone  changes  and 
the  X-ray  should  be  employed  to  clear  up  a  case  that  offers  any 
difficulties  in  diagnosis.  The  tuberculin  reaction,  inoculation  experi- 
ments in  animals,  or  the  tuberculin  tests,  cutaneous,  percutaneous, 
and  into  the  ocular  conjunctiva,  may  also  be  employed  as  diagnostic 
aids. 

Treatment. — In  the  early  stages,  if  there  is  any  pain,  rest  in  splints 
will  afford  much  relief.  As  pointed  out  by  Taylor,  the  diet  should 
be  nutritious  and  not  restricted.  Later  massage  and  careful  passive 
movements  combined  with  baths  sometimes  lead  to  success.  Ortho- 
pedic appliances  and  surgical  intervention  are  often  necessary  to 
correct  resulting  deformities. 

Still's  Disease. — This  is  a  polyarthritis  occurring  in  childhood 
which  is  as  yet  little  understood.  Clinically,  it  seems  related  to  certain 
forms  of  chronic  sepsis  or  tuberculosis. 

There  develops  an  enlargement  and  partial  ankylosis  of  the  joint 
with  some  temperature  of  an  irregular  type  associated  with  splenic 
hypertrophy,  and  quite  general  enlargement  of  the  liver  and  lymphatic 
glands. 

As  distinguished  from  the  other  rheumatoids,  the  disease  does 
not  tend  to  destructive  changes  in  the  joints,  and  in  fact  seems  to  be 
self-limited.  Following  the  suggestion  of  Nathan,  thymus  extract  in 
five-  to  twenty-grain  doses  three  times  a  day  may  be  given. 

Malaria. 
(Paludism.) 

Malaria  is  an  infectious  disease  caused  by  the  hemacytozoon  of 
Laveran,  and  characterized  by  a  periodic  intermittent  or  remittent 
fever. 

Etiology. — The  parasite  is  carried  through  the  anopheles  mosquito 
which  is  distinguished  from  the  common  mosquito  or  culex  by  the 
following  characteristics  (see  Fig.  87) : 

Anopheles.  Culex. 

1.  Two  large  palpi  on  side  of  1.  Small  palpi. 

proboscis. 

2.  Mottled  wings.  2.  No  spots  on  wings. 

3.  Body  held  at  an  angle  45°  3.   Body  held  parallel. 

or  more.  Posterior  legs  often  crossed 

over  back. 

4.  More  often  found  in   the  4.  More  often  found  in  cities. 


country. 


20 


306 


DISEASES  OF  CHILDREN. 


The  parasite  of  Laveran  occurs  in  three  forms:  the  tertian, 
quartan,  and  estivoautumnal. 

In  the  fall  of  the  year  the  greater  number  of  cases  are  seen. 
Regions  in  which  much  marsh  land  is  found  are  favorable  places  for 
the  breeding  of  the  anopheles,  and  in  these  localities  rnalaria  is  natur- 
ally more  prevalent. 


Fig.  87, — A,  Anopheles  claviger;  B,  Specimen  of  culex;  C,  Different 
positions  assumed  by  Anopheles  and  Culex  when  at  rest. 


Pathology. — The  tertian  variety  develops  in  the  human  organism 
in  forty-eight  hours.  At  first  there  is  seen  a  small  ovoid  particle 
within  a  red  blood-cell.  Pigmentation  appears  as  development  pro- 
gresses around  the  periphery  of  the  parasite.  Ameboid  movements 
may  be  noted.  The  hemoglobin  of  the  red  cell  appears  to  be  destroyed 
by  the  parasite.  Segmentation  now  takes  place,  creating  the  spores 
which  are  freed  in  the  blood  stream  and  are  ready  to  attack  new  red 
cells,  and  then  pass  through  a  similar  cycle  of  development. 


THE  INFECTIOUS  DISEASES.  307 

The  quartan  type  completes  its  development  in  seventy-two 
hours,  producing  the  characteristic  paroxysms  on  the  fourth  day,  in- 
stead of  on  the  third  as  in  the  tertian  type. 

It  may  be  differentiated  from  the  tertian  by  the  lack  of  move- 
ment on  the  third  day,  and  by  the  peculiar  yellowish-green  color  of  the 
cell,  and  by  the  rosette  appearance  on  the  fourth  day. 

The  estivoautumnal  variety  takes  twenty-four  to  forty-eight 
hours  to  complete  its  cycle,  and  cresentic  forms  appear  after  a  week  of 
development.  The  parasite  is  sparsely  pigmented  and  smaller  in  size. 
The  gametocytes  or  sexually  differentiated  types  develop  only  in  the 
intermediate  host.  Sporozoids  develop  in  the  host  or  mosquito,  and 
through  its  salivary  glands  infect  the  bitten  individual  where  they 
develop  into  parasites  and  pass  through  one  of  the  cycles  as  just 
described. 

In  mild  cases  of  malaria  little  alteration  in  the  body  structures 
may  be  found  besides  an  enlarged  spleen  and  changes  in  the  blood. 
Malaria  is  rarely  fatal  in  infants  and  children. 

In  the  pernicious  forms  both  the  liver  and  spleen  are  enlarged. 
In  chronic  malaria  the  spleen  and  sometimes  the  liver  become  hard 
and  deeply  pigmented. 

Symptomatology. — In  infants  (in  whom  it  is  quite  rare)  and  in 
younger  children  the  symptoms  are  irregular  in  form  and  the  diagnosis 
often  obscure.  In  older  children  the  typical  adult  type  is  seen,  pre- 
senting 1  ttle  or  no  difficulty  in  diagnosis.  A  distinct  chill  or  chilly  sen- 
sations and  sometimes  a  convulsion  may  usher  in  an  attack. 

The  child  has  been  listless  for  several  days  or  complains  of  being 
tired,  stretches,  and  yawns.  The  extremities  are  cold,  and  the  child 
seeks  its  bed  for  warmth. 

The  common  type  in  infants  and  younger  children  results  from 
a  double  infection  with  the  tertian  parasite,  producing  the  so-called 
quotidian  fever.  The  temperature  is  high  with  a  corresponding  pulse 
rate. 

The  estivoautumnal  type  is  not  often  met  with;  it  produces  a 
very  irregular  form  of  fever  with  or  without  a  definite  paroxysm. 
The  fever  may  be  intermittent  or  even  remittent  in  type;  that 
is,  a  cont  nuous  fever  with  small  excursions  and  no  drop  to  the 
normal. 

In  older  children,  as  has  been  said  above,  the  adult  type  is 
simulated.  The  period  of  chill  is  followed  by  the  stage  of  fever  and 
more  or  less  perspiration.  The  temperature  reaches  104°  or  105°  F.  and 
is  accompanied  by  headache,  often  vomiting  and  extreme  thirst. 
A  normal  or  subnormal  temperature  follows  after  the  period  of  high 


308  DISEASES  OF  CHILDREN. 

fever.  The  succeeding  day  a  robust  child  may  be  willing  to  go  about 
and  play  as  usual. 

In  the  cities  we  see  a  subacute  variety,  usually  in  children,  about 
the  fifth  year  of  age.  They  are  brought  because  they  are  on  differ- 
ent days  listless,  pale,  and  without  ambition.  The  physical  examina- 
tion often  shows  an  enlarged  spleen  and  characteristic  blood  changes. 
True  chills  are  not  experienced  nor  does  one  obtain  a  history  of  fever 
followed  by  perspiration. 

Malarial  cachexia  and  the  pernicious  forms  of  malaria  are  rarely 
seen  among  children  in  the  United  States,  at  least  in  the  North.  In 
the  cachectic  or  chronic  type,  the  spleen  is  uniformly  large  and  firm, 
sometimes  extending  to  the  crest  of  the  ilium.  In  these  cases  the  liver 
is  apt  to  be  enlarged.  The  child  is  extremely  anemic,  has  a  greenish- 
yellow  tinge,  and  a  poor  complexion.  Loss  of  appetite  and  constipation 
are  commonly  found.  The  urine  is  highly  colored  and  may  contain 
casts  and  blood. 

Differential  Diagnosis. — Malaria  must  be  differentiated  from 
typhoid,  secondary  anemia,  Banti's  disease,  and  certain  forms  of  neph-. 
ritis.  Repeated  examinations  of  a  fresh  or  stained  specimen  of  blood, 
or  both,  should  be  made  for  evidences  of  the  malarial  organism. 

The  therapeutic  test  with  quinin  may  be  made  in  suspected  cases 
in  which  a  blood  examination  is  not  feasible. 

The  uniformly  enlarged  spleen  found  in  malaria  is  a  diagnostic 
feature  of  great  importance.  The  spleen  is  said  to  be  enlarged  in  a 
child  when  it  can  be  felt.  The  Widal  test  and  a  differential  blood 
count  will  often  assist  in  fixing  the  diagnosis  when  a  careful  physical 
examination  including  the  ears  has  been  made  to  exclude  other  con- 
ditions. 

Treatment.  Prophylactic. — The  physician  should  be  acquainted 
with  the  genus  of  mosquito  in  his  localit3%  If  the  anopheles  are  present 
he  should  insist  upon  the  authorities  taking  all  possible  measures  to 
drain  the  swampy  areas.  The  children's  cribs  should  be  closely 
screened.  Water  barrels  and  similar  tanks  must  be  protected  by 
screens  to  prevent  the  development  of  larvae.  The  latter  may  be 
killed  by  the  use  of  crude  petroleum  floated  over  infested  pools. 

Therapeutic. — An  initial  purge  with  calomel  is  recommended. 
The  early  and  continued  use  of  quinin  until  a  cure  is  effected  is  es- 
sential in  any  of  the  forms  above  mentioned.  Relatively  larger  doses 
may  be  given  to  children  than  to  adults.  For  infants  and  younger  chil- 
dren, the  soluble  bisulphate  is  recommended.  Its  bitter  taste  is  often 
less  objected  to  by  younger  children  than  by  their  elders.  The  syrup 
of  yerba  santa  best  disguises  its  bitter  taste  if  any  addition  is  neces- 


THE    INFECTIOUS  DISEASES.  309 

sary.  Euquinin  and  tannate  of  quinin  are  tasteless  preparations 
which  may  be  given  in  mild  cases.  The  sulphate  of  quinin  in  half- 
grain  doses  may  be  made  more  palatable  by  the  use  of  chocolate  in 
tablets  or  lozenges. 

The  year-old  child  may  be  given  one  grain  of  the  sulphate  or  bi- 
sulphate  every  three  hours.  A  child  of  five  years,  three  grains  every 
four  hours.  Larger  doses  may  be  given  on  well  days,  and  decreased 
or  omitted  during  the  paroxysms.  Where  the  stomach  is  irritable  and 
the  quinin  not  retained,  rectal  injections  of  the  bisulphate  may  be 
made,  preferably  in  a  mucilaginous  suspension. 

Suppositories  of  quinin  are  not,  very  satisfactory  for  continued 
usage.  The  hydrochlorate  or  bimuriate  of  quinin  in  cocoa-butter 
should  be  used  for  this  purpose.  The  hypodermatic  administration 
of  quinin  in  children  in  this  country  is  unnecessa,ry  and  uncalled  for. 

The  chill  is  combated  with  a  number  of  hot-water  bottles,  a  hot 
pack  or  a  hot  bath.  The  oncoming  fever  is  allayed  with  alcohol  spong- 
ing and  cool  drinks  in  small  quantity  at  frequent  intervals. 

Quinin  should  be  administered  for  at  least  a  week  following  the 
last  symptoms  of  malar' a.  The  elixir  of  iron,  quinin  and  strychnia 
will  do  much  to  combat  the  resulting  anemia,  a  half-dram  three 
times  a  day  after  meals  to  a  five-year-old  child.  Fowler's  solution  or 
Warburg's  tincture  are  useful  in  the  long-standing  cases. 

Erysipelas. 

This  is  a  constitutional  infectious  disease  presenting  a  diffuse, 
rapidly  spreading  inflammation  of  the  skin  and  subcutaneous  con- 
nective tissue,  and  occasionally  of  the  mucous  membranes. 

Etiology. — No  specific  organism  has  been  found  in  erysipelas, 
but  a  streptococcus  is  thought  to  be  usually  the  active  cause.  It 
may  occur  in  connection  with  a  septic  condition  of  the  mother  during 
or  shortly  after  birth.  The  virus  enters  the  system  through  an 
abrasion  of  the  skin  or  mucous  membrane. 

Symptomatology. — The  disease  is  more  apt  to  occur  during 
infancy  than  childhood,  and  the  earlier  it  appears  after  birth  the  more 
serious  will  be  its  effects.  In  robust  infants  the  inflamed  skin  will 
present  a  deep-red  color,  while  in  feebler  babies  it  will  be  lighter,  pre- 
senting more  of  a  pinkish  appearance.  The  deeper  tissues  may 
likewise  be  involved  in  a  phlegmonous  inflammation  in  severe  cases, 
and  there  may  also  be  edema  and  finally  some  desquamation.  In  the 
newly-born  the  disease  is  apt  to  be  contracted  from  some  septic 
condition  of  the  mother.     It  may  then  start  at  the  umbilicus,  in  the 


310 


DISEASES  OF  CHILDREN. 


genital  region,  or  from  some  point  of  abrasion  consequent  to  the 
delivery.  Where  the  umbilicus  is  affected,  the  disease  is  apt  to  extend 
inward,  producing  a  peritonitis.  In  other  cases  pneumonia  or  empy- 
ema may  ensue  and  hasten  the  fatal  ending.  In  older  infants  the 
disease  begins  on  some  abrasion  of  the  skin,  frequently  around  the 
genital  organs,  but  sometimes  on  the  trunk,  arms,  or  legs.  It  is  not  so 
apt  as  in  adults  to  attack  the  face  and  scalp.     The  cutaneous  redness 


Fig.  88  — Erysipelas,  which  began  on  the  face  and  spread  over  the  body. 

and  subcutaneous  infiltration  spread  rapidly,  but  with  a  sharp  line  of 
demarcation  between  the  diseased  and  healthy  skin.  The  affected 
part  is  usually  hot  to  the  touch.  The  constitutional  symptoms  are 
commonly  severe,  with  evidences  of  prostration.  The  result  of  the 
pricking  or  burning  pain  is  seen  in  great  restlessness,  disturbed  sleep, 
and  occasionally  convulsions.  The  fever  is  irregular  and  high  where 
much  of  the  skin  is  involved.  The  pulse  is  usually  rapid  and  feeble. 
There  may  be  evidence  of  gastroenteric  irritation,  shown  either  by 
vomiting  or  diarrhea.  In  fatal  cases  death  usually  results  from 
exhaustion  or  from  some  complicating  disease,  such  as  peritonitis  or 


THE   INFECTIOUS  DISEASES.  311 

pneumonia.  Abscesses  and  even  sloughing  of  tissues  may  accompany 
severe  and  deep-seated  erysipelas.  The  tendency  to  spread  is  shown 
in  some  cases  by  the  whole  surface  of  the  body  becoming  involved. 
There  is  frequently  in  infants  a  recurrence  of  the  inflammation 
involving  the  same  surfaces  as  were  originally  attacked.  The  disease 
may  last  from  one  to  three  or  four  weeks. 

Prognosis. — The  prognosis  will  vary  with  the  age  of  the  infant 
and  the  extent  of  the  inflammation.  It  is  very  fatal  during  the  first 
month,  and  from  that  period  up  to  the  sixth  month  the  outlook  will  be 
uncertain.  After  six  months  the  prognosis  is  good.  Constitutional 
symptoms  are  usually  less  severe  when  the  arms  and  legs  are  involved 
than  when  the  disease  affects  the  region  around  the  umbilicus  or  the 
neck  and  head.  If  the  inflammation  is  superficial  and  spreads  slowly, 
the  prognosis  is  naturally  more  favorable  than  when  it  spreads  rapidly 
and  is  more  deep-seated  with  the  character  of  a  cellulitis. 

Treatment. — While  the  disease  cannot  be  aborted,  every  effort 
must  be  made  to  sustain  the  strength  of  the  infant  by  simple,  nourishing 
diet.  If  the  mother  is  septic,  the  baby  must  be  removed,  from  the 
breast,  but  otherwise  maternal  feeding  offers  the  best  chance  for 
recovery.  In  bottle  babies  it  may  be  necessary  to  weaken  the  formula 
or  to  peptonize  when  there  are  evidences  of  digestive  disturbances. 
We  believe  that  tincture  of  the  chlorid  of  iron  is  beneficial,  and  an 
infant  of  a  year  old  may  be  given  three  or  four  drops,  well  diluted,  every 
three  hours.  As  it  is  an  asthenic  disease,  it  is  often  necessary  to 
stimulate,  giving  strychnin  or  whisky  when  the  pulse  is  weak.  Many 
cooling  and  antiseptic  applications  have  been  tried  upon  the  skin, 
but  with  doubtful  results.  Ichthyol,  a  dram  to  the  ounce,  may  be 
employed  to  relieve  itching  and  burning  and  act  as  a  local  antiseptic. 
Infants  with  erysipelas  should  be  isolated,  particularly  when  near 
surgical  cases  or  those  apt  to  have  any  abrasion  of  the  skin  or  mucous 
membranes.  Their  clothing  and  bedding  should  be  disinfected  at 
the  termination  of  the  disease. 

The  polyvalent  streptococcic  serum  may  be  tried  in  desperate 
cases,  but  our  experience  with  its  use  prevents  its  recommendation  as 
a  general  remedial  measure. 


CHAPTER  XXIII. 
DISINFECTANTS  AND  DISINFECTION. 

Disinfection  has  for  its  object  the  limitation  of  an  infective  process 
already  begun,  the  protection  of  those  already  exposed  and  the  pre- 
vention of  the  spread  of  the  infection  to  others. 

The  disinfectants  commonly  used  may  be  divided  into  two  groups, 
the  aerial  and  the  chemical. 

Aerial. 

[  1.  Formaldehyd. 

2.  Superheated  steam. 

3.  Sulphurous  acid  (sulphur  dioxid). 

4.  Chlorin. 

Chemical. 

1.  Mercurial  salts. 

2.  Carbolic  acid. 

3.  Calx  chlorata  (chlorid  of  lime). 

4.  Formalin,  etc. 

Formaldehyd  gas  is  the  best  agent  known  at  present  for  disinfec- 
tion of  dwellings.  If  fairly  concentrated,  it  kills  bacilli  and  their 
spores.  It  acts  rapidly,  is  less  injurious  in  its  effects  on  household 
goods,  and  is  less  toxic  to  the  higher  forms  of  animal  life. 

To  use  formaldehyd,  either  of  the  following  methods  can  be 
recommended. 

II  (a)  Formaldehyd  Generator. — A  serviceable  apparatus  known  as 
the  Novy  generator  can  be  purchased  for  about  four  dollars.  This 
consists  of  a  copper  boiler  from  which  leads  a  tube;  the  latter  is  pushed 
into  the  keyhole  of  the  door.  About  ten  ounces  of  formalin  solution  (40 
per  cent.)  is  added  to  a  quart  of  water  in  the  boiler  and  an  alcohol 
lamp  or  "Primus"  blast  lamp  placed  underneath  and  the  whole 
boiled.  On  boiling,  formaldehyd  gas  is  liberated  and  led  into  the 
room  through  the  tube.  One  thousand  cubic  feet  of  room  space  can 
be  disinfected  with  the  above  amount. 

(b)  Method  of  Houghton  and  Clark. — Place  240  gm.  of  potassium 
permanganate  in  a  three-gallon  pail  and  put  this  in  a  tub  or  on  a  large 
zinc  stove;  add  480  c.c.  formol  to  this.      Violent  ebullition  and  foam-' 

312 


DISINFECTANTS  AND  DISINFECTION.  313 

ing  results  and  formaldehyd  gas  is  liberated.  This  will  disinfect  1,600 
cubic  feet  of  space.  The  potassium  permanganate  can  be  mixed  with 
15  per  cent,  of  Portland  cement  and  enough  water  to  make  the  mix- 
ture of  sufficient  consistency  to  mould  into  bricks.  The  action  in  this 
form  will  be  slower  and  less  violent,  although  just  as  efficient.  Place 
the  formol  (480  c.c.)  in  the  pail  and  add  three  bricks  made  as  above, 
each  containing  80  gm.  of  potassium  permanganate. 

(c)  If  paraform  is  used,  1,000  grams  are  required  for  every  1,000 
cubic  feet  of  air  space,  the  exposure  lasting  for  at  least  six  hours. 

Superheated  steam  is  the  most  efficient  measure  for  disinfec- 
tion known.  Its  use,  however,  is  limited  to  institutions  having  an 
autoclave. 

Sulphurous  acid  results  when  sulphur  is  burned  in  air.  Its  potency 
is  many  times  increased  if  the  air  is  moist.  When  intensified  in  this 
way,  this  gas  will  destroy  the  non-sporing  bacteria  when  in  full  con- 
tact. Spores  are  not  killed  even  after  long  exposure.  To  fumi- 
gate by  this  method  calk  or  seal  the  room  with  adhesive-plaster  strips 
and  have  a  pan  of  water  boiling  in  the  room  to  provide  moisture.  It 
will  be  necessary  to  burn  four  pounds  of  sulphur  per  1,000  cubic  feet 
and  allow  an  eight-hour  exposure.  It  is  well  to  place  the  receptacle 
containing  the  sulphur  on  a  low  iron  tripod  which  stands  in  a  large 
pan  of  water.  Two  or  three  ounces  of  alcohol  poured  over  the  sulphur 
before  igniting  it  will  insure  good  combustion. 

The  objections  to  this  method  are:  (a)  a  good  exposure  of  infected 
surfaces  is  difficult  to  obtain  as  in  books,  mattresses,  carpets,  etc.; 
(b)  spores  are  not  destroyed;  (c)  wall  paper,  pictures,  and  colored 
hangings  are  bleached  or  discolored;  (d)  all  metallic  articles  are 
blackened  by  the  sulphide  formed. 

Chlorin  is  formed  when  a  strong  mineral  acid  is  mixed  with 
chlorinated  lime.  Two  pounds  of  the  powder  with  an  excess  of  the 
acid  being  used  for  1,000  cubic  feet  of  space.  Chlorin  is  open  to  the 
same  objections  as  the  sulphur  fumes  when  used  as  a  disinfectant. 

Mercurial  salts  stand  first  among  chemical  disinfectants;  the 
bichlorid,  the  bin'odid,  and  the  cyanid  all  being  employed;  of  these, 
the  bichlorid  is  the  most  potent  and  is  most  extensively  employed. 
A  solution  of  1  to  1,000  will  kill  non-sporing  bacteria  in  one  minute 
and  anthrax  spores  in  ten  minutes.  Behring  has  shown  that  its  effi- 
ciency is  in  inverse  ratio  to  the  amount  of  albuminous  matter  present 
in  the  material  treated.  With  albuminous  material,  bichlorid  forms 
an  insoluable  albuminate  which  prevents  destruction  of  the  inner 
portions.  This  feature  makes  bichlorid  of  mercury  less  suitable  for 
use  in  disinfecting  sputum,  pus,  or  blood. 


314  DISEASES  OF  CHILDREN. 

Carbolic  acid  in  a  one  to  twenty  or  5  per  cent,  solution  will 
rapidly  destroy  non-sporing  bacteria,  although  their  spores  are  not 
destroyed  for  several  weeks.  Albumin,  if  present,  impairs  its  efficiency 
only  slightly.  Cresol,  a  derivative  of  carbolic  acid,  is  also  an  excellent 
disinfectant. 

Calx  chlorata  (chlorid  of  lime)  depends  upon  the  formation  of 
hypochlorous  acid  for  its  efficiency.  The  alkalinity  of  the  lime 
present  renders  a  solution  of  this  agent  most  valuable  for  disinfect- 
ing albuminous  material,  as  it  first  disintegrates  and  then  disinfects. 
For  practical  purposes,  no  other  chemical  can  compare  with  this  agent 
for  the  disinfection  of  sputum  and  feces.  If  equal  parts  of  a  dilute 
solution  of  acetic  acid  (1.25  per  cent.)  or  vinegar  and  a  saturated  solu- 
tion of  chlorid  of  lime  are  mixed  together  this  agent  will  destroy  spores 
in  one  minute.  Chlorid  of  lime  rapidly  deteriorates  if  left  uncovered, 
due  to  liberation  of  the  hypochlorous  acid.  Herein  lies  the  greatest 
objection  to  this  agent,  for  much  of  the  chemicals  sold  in  the  shops  is 
too  old  to  be  efficient. 

Formalin  is  a  40  per  cent,  solution  of  formaldehyd  gas  in  water. 
In  solution  its  action  is  not  as  effective  as  would  be  expected,  and  there- 
fore it  has  not  come  into  general  use.  As  a  gas,  its  potency  is  note- 
worthy and  has  been  discussed  under  Aerial  Disinfection. 

The  Sick-room  in  Infectious  Diseases. — Infection  may  be  carried 
in  the  sputum,  in  the  throat  secretions,  in  discharges  from  the  nose 
and  ear,  in  skin  debris,  in  exudations,  in  conjunctival  or  abscess  dis- 
charges, and  in  the  urine  or  stools.  The  sick-room  should  be  stripped 
of  superfluous  fittings;  it  should  be  in  a  remote  part  of  the  house,  and 
preferably  on  the  top  floor.  A  large  room  with  plenty  of  ventilation 
and  sunshine  and  with  an  open  fire  should  if  possible  be  selected.  A 
gown  and  hood  should  be  provided  for  the  physician  and  hung  in  a 
separate  outside  closet  where  it  can  be  later  disinfected.  All  clothing 
worn  by  the  attendants  in  the  sick-room  should  be  washable,  and  a  com- 
plete change  should  be  made  before  mingling  with  the  members  of  the 
household.  When  changes  in  linen  are  made  for  the  patient  or  atten- 
dant the  articles  are  to  be  rolled  up  in  a  bundle  and  put  to  soak  for 
twenty-four  hours  in  a  carbolic  (1  to  20)  solution  before  being  sent  to 
the  laundry,  where  they  are  to  be  washed  separately. 

When  it  is  known  that  anyone  has  been  exposed  to  an  infectious 
disease,  they  should  be  isolated  as  soon  as  possible  and  given  a  bi- 
chlorid  of  mercury  (1-5,000)  bath  and  a  complete  change  of  clothing. 
Such  individuals  should  be  kept  under  close  observation  until  the 
incubation  period  for  that  particular  disease  has  passed. 

Scrupulous  cleanliness  with  regard  to  the  excreta  and  discharges  of 


DISINFECTANTS  AND  DISINFECTION.  315 

the  patient  is  imperative.  Soft  Japanese  paper  napkins  are  most  con- 
venient for  wiping  nose  and  throat  discharges.  They  must  be  burned 
at  once  after  use.  Carbolated  vaseUn  rubbed  over  the  skin  of  patients 
suffering  from  variola,  varicella  and  scarlet  fever  prevents  the  pus, 
exudations,  and  epithelial  debris  from  drying  and  being  scattered. 
Urine  and  stools  should  be  treated  with  equal  volumes  of  carbolic  acid 
solution  (1  to  20),  bichlorid  of  mercury  (1  to  1,000)  or  chlorid  of  lime 
(1  to  50),  and  allowed  to  stand  three  or  four  hours  before  disposing  of 
them.  Large  masses  in  stools  should  be  broken  up  to  insure  thorough 
disinfection.  In  cases  in  which  the  throat  is  involved,  frequent  gar- 
gles of  chlorin  water,  potassium  permanganate  (1  to  300),  formalin 
1  per  cent,  or  peroxid  of  hydrogen  reduce  the  number  of  bacteria 
in  the  expired  air  besides  having  a  beneficial  effect  on  the  patient. 
Dishes  and  utensils  used  by  a  patient  are  to  be  placed  for  an  hour  in  a 
large  receptable  containing  carbolic  solution  (1  to  20)  and  then  boiled 
or  scalded. 

The  remains  of  one  dying  of  an  infectious  disease  should  be  em- 
balmed with  a  fluid  which  will  stand  the  bacteriological  test.  Close 
all  external  openings  of  the  body  with  absorbent  cotton  and  give  a 
thorough  sponge  bath  (including  the  hair)  using  carbolic  solution 
(1  to  20)  or  bichlorid  of  mercury  (1  to  1,000). 

The  following  plan  is  recommended  for  the  disinfection  of  the 
room  where  a  patient  with  an  infectious  disease  has  been  treated: 
1.  close  all  openings  in  windows,  walls,  and  floors  by  calking  or  pasting 
strips  of  paper  or  adhesive  plaster  over  them;  2.  stretch  out  on  a  line 
all  linen,  blankets,  and  carpets  contained  therein;  3.  spray  with  water 
the  floors,  walls,  and  all  articles  in  the  room;  4.  introduce  the  disin- 
fecting gas  and  allow  the  room  to  remain  closed  up  for  twelve  hours. 


CHAPTER  XXIV 
TUBERCULOSIS. 

Tuberculosis  is  an  infective  fever  caused  by  the  toxins  of  the 
tubercle  bacillus,  and  characterized  by  the  formation  of  heteroneo- 
plasms  called  tubercles.  Any  organ  or  part  of  the  body  may  be  at- 
tacked. The  disease  may  be  confined  to  certain  organs  or  may  be 
generalized,  occurring  at  the  same  time  in  many  parts  of  the  body. 

Etiology. — The  tubercle  bacillus  upon  which  tuberculosis  in  any 
or  all  of  its  manifestations  depends,  is  a  rod-shaped,  facultative,  color- 
less bacillus,  slightly  bent  and  having  rounded  ends.  In  size  it  is  about 
one-fourth  to  one-half  the  diameter  of  a  red  blood-cell.  It  is  especially 
distinguishable  for  its  staining  properties.  It  strongly  resists  decolori- 
zation  after  having  been  stained  with  acid  dyes. 

There  are  several  varieties  of  the  bacillus.  We  are  mainly 
concerned  here  with  the  human  and  bovine  types.  The  controversy 
regarding  these  types  is  not  yet  settled,  but  the  distinction  still  seems 
to  be  a  strong  one  between  these  forms. 

The  bovine  type  of  bacillus  differs  somewhat  in  form,  being  more 
irregular,  thicker  or  oval  in  shape  with  blunted  ends.  The  types  may 
also  be  differentiated  by  cultural  methods.  This  method,  however, 
is  suitable  only  for  a  laboratory  specialist. 

The  bacillus  is  easily  destroyed  by  sunlight  or  heat,  either  dry 
or  moist,  but  is  not  affected  by  low  temperatures. 

The  disease  occurs  at  all  ages— fetal  tuberculosis  has  been  re- 
corded (Jacobi,  WoUstein,  and  others). 

The  invading  microorganism  gains  entrance  to  the  body  through 
three  main  channels,  given  in  the  order  of  their  relative  importance; 
through  the  respiratory  tract,  through  the  intestinal  tract,  and  through 
wounds  and  abrasions  of  the  skin.  Infants  and  children  are  infected 
mainly  through  the  respiratory  tract. 

Hereditary  predisposition  is  still  the  subject  of  argument,  but  the 
position  held  by  Adami  appeals  to  us.  He  believes  that  two  possi- 
bilities may  result  from  parental  tuberculosis;  the  offspring  may  be- 
come especially  susceptible  if  the  germinal  cells  become  weakened 
by  progressive  disease,  or  if  the  disease  is  well  resisted  the  child  may 
acquire  an  increased  resistance  to  the  disease. 

316 


TUBERCULOSIS. 


317 


Parental  diseases,  nutritional  faults  and  developmental  defects 
in  the  parents  often  leave  the  offspring  with  a  lowered  resistance  to* 
tuberculosis. 

A  child  with  poor  muscular  development,  with  a  flat  and  narrow 
chest  and  small  abdomen  is  considered  to  have  a  disposition  to  tuber- 
culosis;    we    can    add    to    this 
class  children  who   are  mouth- 
breathers   and   have  defects   of 
the  nose  and  mouth. 

In  childhood  there  is  little 
resistance  to  the  disease;  the 
glands,  meninges,  bones,  joints, 
and  lungs  are  easily  invaded  and 
are  believed  by  v.  Behring  often 
to  remain  latent  and  develop  in 
later  life  into  the  pulmonary 
form. 

Again,  in  childhood  the 
disease  is  not  apt  to  develop  at 
the  site  of  infection  as  in  adults, 
but  extends  to  other  tissues  and 
forms  tubercles  there.  The 
entity  known  as  scrofula  is  still 
acceptable  to  Continental 
Europe;  but  in  America  the 
weight  of  opinion  is  that  scrofula 
indicates  tuberculosis,  and  we 
believe  with  Baldwin  that  it  can 
be  used  to  mean  an  important 
predisposition  to  pulmonary 
tuberculosis,  which  he  says  is 
associated  with  it  in  25  per  cent, 
of  all  cases.  Measles,  whooping 
cough,  diphtheria,  pneumonia, 
influenza  and,  in  a  lesser  de- 
gree, scarlet  fever,  tonsillitis,  and  variola  are  often  the  precursors  of 
tuberculosis,  because  of  their  efifect  on  the  mucous  membranes  and 
lymph-glands  accompanied  by  the  lowered  resistance  of  the  conva- 
lescent child. 

Rickets,  too,  is  a  disease  favoring  tuberculous  infection  when 
accompanied  by  defective  nutrition  and  thoracic  deformities.  Finally, 
gastrointestinal  diseases  from  their  destructive  action  on  the  mucous 


Fig.  89. — Conformation  of  the  chest  com- 
monly seen  in  tuberculous  children. 


318  DISEASES  OF  CHILDREN. 

membranes  lead  sometimes  to  open  infection  and  probably  often  to  the 
latent  form. 

The  children  of  poor  parents  in  unsanitary  surroundings,  whether 
in  city  or  even  in  the  country,  are  prone  to  the  infection,  which  they 
may  receive  from  the  following  sources:  Human  sputum,  through 
food  objects  or  dust,  urine  or  feces  on  soiled  clothing  or  beds.  Milk  of 
tuberculous  cattle  has  been  held  as  a  distinct  source  of  danger,  but 
the  case  has  not  been  fully  proven.  Certainly,  bovine  tuberculosis  in 
our  experience  is  a  minor  factor  in  the  causation  of  the  human  form 
of  the  disease.  Milk  as  a  food,  however,  may  be  indirectly  contami- 
nated by  dust  or  infected  containers.  Infants  at  the  breast  have  been 
infected  by  their  mother's  soiled  hands  or  her  kisses. 

Cornet  reports  infection  by  midwives  who  blew  into  the  mouths 
of  the  infants  to  start  up  respiration. 

Children  are  intimately  connected  with  the  fact  that  tuberculosis 
is  a  "family  disease" — 40  to  60  per  cent,  disclosing  a  history  of  other 
cases  in  the  household;  and  this  close  contact  is  the  great  infecting 
method :  the  nursling  infected  by  close  touch  with  its  mother,  the  creep- 
ing infant  on  the  contaminated  floor  carrying  all  things  to  its  mouth, 
the  school  boy  trading  toys — all  show  at  a  glance  the  numberless  ways 
in  which  children  may  become  tuberculous. 

Tuberculous  Adenitis. 

This  may  be  confined  to  certain  groups  of  lymph-glands,  as  the 
cervical  or  bronchial,  or  there  may  be  an  involvement  of  all,  or  nearly 
all,  the  lymph  nodes  of  the  body. 

The  glands  become  infected  by  access  of  tubercle  bacilli  through 
the  lymph  channels.  The  point  of  entrance  may  have  been  only  a 
slight  abrasion  or  some  form  of  dermatitis.  The  glands  may  also 
become  infected  from  tuberculous  lesions  in  their  vicinity. 

A  cross  section  of  a  tuberculous  gland  shows  the  parenchyma 
swollen  and  hyperplastic,  grayish  in  color,  containing  nodules  varying 
in  size,  some  of  which  are  undergoing  caseation.  If  the  latter  process 
is  advanced,  the  gland  is  soft  and  the  tubercles  are  found  at  the  margins 
only.  The  glands  most  commonly  involved  are  those  at  the  root 
of  the  lung.  The  mesenteric  lymph  nodes  are  frequently  infected  in 
children  and  are  the  usual  accompaniment  of  the  miliary  and  general- 
ized forms. 

Symptomatology. — The  subjects  of  tuberculous  adenitis  are,  as  a 
rule,  anemic  children  of  the  blond  type.  The  appetite  is  capricious 
or  lost,  the  weight  decreases,  and  at  this  time  the  parent  may  notice 


TUBERCULOSIS.  319 

an  enlargement  of  a  gland  or  group  of  glands.  They  are  not  painful 
to  the  touch,  growing  slowly  but  steadily;  sometimes  there  is  a  rise 
of  fever,  especially  in  the  evening.  Physical  examination  may  show 
tuberculous  lesions  elsewhere  in  the  body.  If  the  cervical  lymph 
nodes  are  involved  the  tumors  are  at  iirst  found  in  relation  with  the 
sternocleido  mastoid  muscle.  At  first  they  are  freely  movable,  but 
the  chain  of  glands  increasing,  they  soon  adhere  one  to  the  other, 


Fig.  90. — Tuberculous  adenitis  of  the  cervical  and  axillary  glands. 

forming  sometimes  large  masses  which  may  even  cause  mechanical 
obstruction.  Bilateral  involvement  is  not  uncommon.  The  overlying 
skin  now  becomes  attached  to  the  mass  below,  and  when  the  glands 
caseate  the  skin  is  thickened  and  loses  its  normal  color,  often  becoming 
purplish-red.  If  there  is  no  surgical  intervention  the  glands  rupture 
through  the  overlying  skin  or  dissect  the  fascial  planes;  the  abscess 
may  discharge  at  some  distant  point.  Often  several  long-persisting 
fistulous  tracts  result. 

In   the   generalized    form,    the   cervical,  inguinal,   and    axillary 


320  DISEASES  OF  CHILDREN. 

glands  show  the  greatest  and  earliest  involvement.  The  children  are 
markedly  anemic  and  often  have  a  variable  amount  of  temperature. 
Wasting  slowly  takes  place  and  new  foci  are  found  developing  in 
other  parts  of  the  body.  Bimanual  rectal  examination  will  show 
the  involvement  of  the  retroperitoneal  and  mesenteric  lymph  nodes. 

When  the  bronchial  lymph  nodes  are  large,  pressure  symptoms 
may  occur,  causing  a  paroxysmal  cough  with  breathing  signs  of 
bronchial  asthma.  In  advanced  cases  dyspnea  is  produced  on  slight 
exertion.  Sometimes  dullness  is  obtained  on  percussion  over  the 
manubrium  which  extends  over  a  varying  area.  This  is  usually 
accompanied  by  tubular  breathing  on  the  left  side. 

Diagnosis. — The  diagnosis  of  tuberculous  adenitis  is  based  upon 
the  slow  course  and  the  absence  of  active  inflammatory  changes,  such 
as  heat  or  pain  on  palpation.  Simple  adenitis  can  usually  be  traced 
to  some  source  of  infection,  as  an  eczematous  area,  caries  of  the 
teeth,  etc.  These  glands  subside  when  the  focus  of  irritation  is  re- 
moved. If  there  are  evidences  of  tuberculosis  in  other  structures, 
tuberculous  adenitis  may  be  suspected. 

The  tuberculin  tests  (p.  54)  may  be  used  to  corioborate  the 
diagnosis.  Syphilitic  glands  are  distinguished  by  their  location. 
The  epitrochlear  glands  show  simultaneous  enlargement  with  other 
syphilitic  manifestations  in  different  parts  of  the  body. 

Lymphosarcoma  is  sometimes  confounded  with  generalized 
tuberculous  adenitis.  This  disease  usually  primarily  involves  the 
retroperitoneal  glands  or  those  within  the  mediastinum.  The  growth 
here  is  rapid,  invading  neighboring  structures,  and  often  producing 
serious  symptoms  before  the  true  nature  of  the  disease  is  suspected. 

Course  and  Prognosis. — It  is  often  difficult  to  predict  the  end- 
result  of  a  tuberculous  adenitis.  The  prognosis  should  always  be 
considered  seriously  as  a  focus  which  may  at  any  time  spread  the 
disease  to  the  lungs  or  other  structures. 

If  the  subject  is  young  and  can  be  placed  in  favorable  sur- 
roundings, restitution  to  the  normal  may  take  place.  Even  degener- 
ated glands  with  fistulous  tracts  may  eventually  terminate  in  a  cure 
under  proper  care. 

Treatment. — Immediate  steps  should  be  taken  just  as  soon  as  the 
diagnosis  is  certain  to  remove  the  child,  if  possible,  to  the  seashore, 
where  it  should  live  in  the  sunshine  and  fresh  air.  The  diet  should 
be  as  nourishing  as  possible,  consisting  principally  of  milk,  eggs, 
cereals,  and  rare  meats.  Cod-liver  oil,  if  well  borne,  should  be  given  twice 
a  day,  after  the  midday  and  evening  meal.  If  this  is  not  acceptable, 
good  results  can  be  obtained  by  increasing  the  quantity  of  butter, 


TUBERCULOSIS.  321 

cream,  or  top  milks.     Sometimes  olive  oil  in  two-dram  doses  twice 
a  day  can  be  substituted  if  the  child  prefers  it. 

Surgical  removal  of  the  glands  may  be  considered  when  they  are 
superficial  and  movable.  The  dissection  is  often  long,  tedious,  and 
dangerous  when  the  glands  are  deep  and  are  in  proximity  to  the  great 
vessels.  General  miliary  tuberculosis  may  follow  the  removal  of 
glands  when  a  clean  dissection  is  impossible.  However,  it  is  some- 
times necessary  to  resort  to  removal  for  the  cosmetic  effect  or  for  the 
relief  of  pressure  symptoms.  Good  results  have  been  obtained  in  a 
number  of  cases  from  radiotheraphy  and  it  would  seem  best  to  counsel 
non-interference  until  these  measures  have  been  given  a  fair  trial. 

Thoracic  Tuberculosis. 

It  is  only  within  recent  years  that  the  frequency  of  pulmonary 
tuberculosis  in  early  life  has  been  correctly  appreciated.  From  a 
study  of  all  necropsies  in  children  under  fifteen  years  of  age,  Harbitz 
at  Christiana  found  tuberculosis  in  42.5  per  cent,  of  all.  Denning 
shows  that  70  per  cent,  of  all  infants  and  children  who  die  from 
tuberculosis  show  tuberculous  changes  in  their  lungs.  Pediatrists 
incline  toward  the  respiratory  tracts,  while  pathologists  lean  toward 
the  alimentary  tract  as  the  principal  portal  of  entry;  the  contro- 
versy, with  much  to  be  said  on  both  sides,  concerns  us  in  regard  to 
prophylactic  measures  to  be  spoken  of  below. 

Tuberculosis  in  early  life  increases  regularly  with  the  age.  It  is 
rare  in  the  first  three  months  of  life,  and  then  almost,  month  by  month, 
the  frequency  increases  steadily.  The  figures  of  Hamburger  and 
Sluka,  obtained  from  2,557  necropsies  on  tuberculous  children  under 
fifteen  years,  report  that  tuberculosis  was  the  direct  cause  of  death 
in  all  those  under  six  months  of  age;  that  it  caused  death  in  75  per  cent, 
of  those  in  the  second  year  of  life,  and  in  the  children  over  two  years 
old  it  became  more  infrequently  the  cause  of  death.  Necropsy  find- 
ings, however,  are  not  absolute  indications  of  the  prevalence  of  tuber- 
culosis in  early  life  since  virulent  bacteria  may  be  present  without 
producing  demonstrable  lesions. 

Tuberculosis  in  early  life  is  a  disease  of  the  lymph  nodes,  but 
after  the  tenth  year  the  pulmonary  form  is  more  prevalent;  and  again 
after  adolescence  the  characteristics  do  not  differ  greatly  from  those 
seen  in  adults. 

Pulmonary  involvement  may  occur  by  direct  infection  from  ca- 
seous tuberculous  glands  through  the  blood  stream  or  by  emboli,  and 
through  the  lymph  channels  from  tuberculous  lymph  nodes,  bones,  or 
pleura. 
21 


322  DISEASES  OF  CHILDREN. 

Pulmonary  Lesions. — The  pathological  anatomy  does  not  differ 
greatly  from  that  seen  in  adult  life,  but  the  areas  involved  are  always 
greater;  in  other  words,  the  disease  is  more  diffuse.  This  is  especially 
true  in  the  first  two  years  of  life. 

In  tuberculous  bronchopneumonia,  which  is  the  predomi- 
nating and  fatal  form,  there  occur  large  caseating  deposits  usually  to  some 
extent  in  both  lungs.  When  a  mixed  infection  occurs  the  nodules  are 
very  apt  to  degenerate.  True  cavities  of  any  size,  however,  are  rarel.v 
seen  in  early  life.  The  glands  at  the  root  of  the  lung  are  invariably 
enlarged  and  often  soft  and  caseating.  The  pleura  is  almost  always 
involved. 

In  miliary  tuberculosis  of  the  lungs,  the  tubercles  are  scattered 
over  the  surface  of  the  lung,  and  in  some  cases  have  been  found 
in  the  parenchyma.  Patches  of  bronchopneumonia  and  congestion 
with  edema  may  be  present,  or  the  lung  may  appear  quite  normal  ex- 
cept for  the  superficial  tubercles. 

Diagnosis. — The  diagnosis  of  incipient  tuberculosis  of  the  lungs 
differs  considerably  in  early  life  from  that  of  adults.  In  the  first 
place  the  apices  of  the  lungs  are  not  most  frequently  involved;  it  is 
the  lower  lobes  or  the  lower  part  of  the  upper  lobe  that  is  primarily 
involved,  which  may  often  be  accounted  for  by  the  proximity  of  the 
bronchial  glands.  The  physical  signs  often  do  not  differ  from  those 
obtained  in  bronchitis  and  bronchopneumonia,  and  the  younger  the 
child  the  more  diffuse  will  be  the  disease.  Therefore  it  is  necessary 
to  employ  every  means  at  our  command  to  perfect  the  diagnosis. 
The  physical  signs  with  the  symptoms  and  the  history  then  become  of 
value. 

In  obtaining  a  history  in  suspected  children,  it  is  especially  im- 
portant to  ascertain  if  the  child  has  been  in  intimate  or  close  contact 
with  a  tuberculous  patient,  or  if  there  has  been  a  slow  convalescence 
from  any  of  the  infectious  diseases,  especially  measles  and  pertussis. 

Gibson  has  called  attention  to  a  venous  dilatation  occurring  over 
the  chest,  neck,  and  shoulders  of  children,  and  tending  to  converge 
above  the  sternum.  This,  when  present,  is  a  valuable  sign,  and  it  is 
probably  due  to  tuberculous  bronchial  lymph  nodes.  If  we  could 
safely  and  surely  diagnosticate  enlarged  bronchial  lymph  nodes  we 
would  have  valuable  confirmatory  evidence.  D'Espine  saj^s  he  has  a 
reliable  method  in  voice  auscultation;  in  the  healthy  child  the  tracheal 
tone  stops  at  the  seventh  cervical  spine,  but  is  heard  below  this  point 
in  pathological  conditions.  Later  on,  dullness  over  the  seventh  cervi- 
cal or  first  dorsal  vertebra  with  intrascapular  dullness  may  be  elicited. 
Cavity  formation  is  rarely  recognized  under  three  years  of  age,  while 


TUBERCULOSIS.  *'     !  0 p  A  3^ 

alter  eight  the  signs  will  simulate  those  in  the  adult.  Expectoration 
is  the  exception  in  children,  while  under  seven  years  hemoptysis  rarely 
occurs  and  practically  is  never  observed  in  those  below  five  years  old. 

Three  groups  of  thoracic  tuberculosis  may  be  distinguished  in 
children;  the  glandular,  tracheobronchial,  and  the  pulmonary.  The 
symptoms  are  never  so  characteristic  as  in  the  adult;  as  a  rule,  there 
is  a  rapid  development  of  symptoms.  If  we  encounter  steady  emacia- 
tion, progressive  muscular  weakness,  an  irregular  temperature  with  a 
fairly  constant  evening  rise,  enlarged  superficial  glands,  with  a  per- 
sistent dry  cough,  we  are  justified  in  utilizing  diagnostic  aids  to  confirm 
the  diagnosis. 

In  adults,  a  diagnosis  may  sometimes  be  made  by  physical  signs 
before  the  tubercle  bacilli  are  found  in  the  sputum.  In  infants  and 
young  children,  however,  we  are  pleased  if  we  obtain  any  sputum  to 
examine,  and  must  be  prepared  to  make  diligent  search  for  the  bacillus. 
Among  the  methods  used  with  success  in  obtaining  sputum  from  in- 
fants is  wrapping  a  piece  of  gauze  on  the  end  of  the  finger  and  irritating 
the  epiglottis  thus  catching  the  sputum.  We  use  an  ordinary  laryn- 
geal swab  wrapped  with  cotton  which  is  quite  effective  and  does  no 
damage  to  the  delicate  mucous  membranes.  The  sputum  being  often 
swallowed,  the  vomitus  or  the  feces  will  also  contain  the  bacilli,  but  the 
search  is  more  arduous. 

The  opsonic  index  has  been  studied  by  numerous  investigators 
in  its  relation  to  tuberculosis,  and  is  considered  of  value  in  obscure 
cases.  Clark  and  Forsyth  have  made  careful  studies,  and  base  their 
diagnosis  on  the  following  variations:  (a)  the  greater  the  fluctuation, 
the  greater  the  certainty  of  diagnosis;  (b)  a  persistently  low  index  is 
diagnostic  of  localized  tuberculous  infection;  (c)  a  persistently  normal 
index  does  not  exclude  tuberculosis,  but  makes  it  less  probable;  (d)  a 
persistently  variable  index  is  diagnostic  of  tuberculous  infection  with 
autoinoculation. 

Ross  states  that  he  has  never  found  an  index  of  1.3  in  a  patient 
not  definitely  tuberculous.  Ogilvy  and  Coffin,  as  a  result  of  their 
studies,  believe  that  the  difficulty  and  tedious  technic  of  estimating 
the  opsonic  index  and  the  wide  variation  obtained  by  various  observers 
make  this  procedure  impracticable  for  diagnosis. 

Injections  of  tuberculin  may  be  used  diagnostically  as  a  last 
resort  if  it  is  imperative  that  a  definite  diagnosis  be  made.  In  children 
the  reaction  is  more  favorable  than  in  adults.  Its  use,  however,  is 
limited  to  those  cases  without  temperature.  The  dose  which  is  safe 
in  children  is  one  ten-thousandth  of  a  c.c.  of  Koch's  old  tuberculin, 
one  three-thousandths  being  the  maximum  dose. 


324  DISEASES  OF  CHILDREN. 

The  agglutination  and  the  heated  serum  tests  have  been  tried, 
and  the  reports  are  quite  uniformly  against  their  practical  value. 
Other  tests,  however,  have  attracted  considerable  attention  and  they 
are  especially  applicable  in  children. 

Von  Pirquet  advanced  the  inoculation  of  Koch's  old  tuberculin 
into  the  skin  in  two  areas,  leaving  one  area  for  control.  Von  Pirquet 
uses  one  part  tuberculin,  diluted  with  one  part  of  a  5  per  cent,  carbol- 
glycerin  solution,  and  two  parts  normal  saline  solution,  of  this  two 
drops  are  inoculated.  The  writer  has  used  one  part  tuberculin  to  three 
parts  saline  solution  freshly  prepared.  Butler  sums  up  his  extensive 
observations  as  follows:  (a)  a  positive  reaction  is  undoubtedly 
diagnostic;  (b)  failure  may  be  expected  in  the  terminal  stages;  (c) 
negative  results  may  be  obtained  in  obsolete  foci  unless  repeated. 
He  believes  the  method  has  distinct  advantages  over  the  hypoder- 
matic use  of  tuberculin.  Calmette,  simultaneously  with  Wolf-Eisner, 
proposed  the  ocular  method  in  which  a  1  per  cent,  solution  of  dry 
tuberculin  in  distilled  water  is  dropped  upon  the  lower  eye-lid  of  the 
eye.  In  three  to  five  hours  a  reaction  occurs,  varying  from  a  slight 
conjunctivitis  to  a  purulent  secretion.  This  test  has  been  quite 
favorably  received,  and  indeed  is  of  distinct  value  in  establishing  an 
early  diagnosis.  Wolf-Eisner  interprets  a  lively  reaction  as  indicative 
of  incipient  tuberculosis,  coupled  with  a  favorable  prognosis,  for  the 
organism  is  then  active  against  the  tubercle  bacilli.  He  believes  the 
eye  test  to  be  of  greater  value  clinically  than  the  cutaneous,  but  would 
use  the  cutaneous  as  a  control.  The  presence  of  conjunctivitis,  bleph- 
aritis, ulcers,  or  trachoma  are  contraindications  for  the  use  of  the 
ocular  test. 

The  Moro  test,  described  on  page  55,  is  simpler  to  perform, 
causing  no  distress  or  unpleasantness  except  slight  itching.  It  may  be 
used  alone  or  as  a  confirmatory  test  to  the  other  methods. 

Pulmonary  Tuberculosis. 

Acute  and  Subacute  Forms. — Etiology. — Mainly  through  the  bron- 
chial lymph  nodes,  the  infection  is  carried  to  the  lungs  of  infants  and 
children;  the  lung  may  be  more  directly  affected,  however,  through  the 
impoverished  mucous  membrane  following  certain  infectious  diseases. 
Tuberculosis  in  other  structures  predisposes  to  lung  infection.  The 
generalized  process  in  the  lungs  is  part,  and  usually  the  termination, 
of  a  miliary  tuberculosis,  while  the  localized  process  is  most  often 
found  close  to  the  bronchial  glands. 

Acute   tuberculous    bronchopneumonia    in    infants    and    young 


TUBERCULOSIS.  326 

children  does  not  markedly  differ  in  its  physical  signs  from  the  simple 
bronchopneumonia,  but  the  period  of  illness  sometimes  lasting  from 
two  to  six  weeks  must  be  suggestive. 

The  fever  is  generally  lower  and  with  smaller  excursions  than  in 
the  ordinary  form  until  the  toxemia  itself  produces  high  evening 
rises  up  to  103°  or  104°  F.  Loss  of  weight  is  slow  but  progressive. 
The  appetite  is  capricious,  the  patient  is  irritable,  easily  tired  and  at 
times  somnolent,  the  bowels  are,  as  a  rule,  constipated,  although 
diarrhea  may  periodically  appear. 

The  fever  causes  restlessness  at  night  and  in  the  morning.  The 
body  and  clothing  may  show  that  sweating  has  taken  place.  The 
cough  is  paroxysmal  in  character,  and  is  apt  to  be  more  frequent 
upon  awakening.  As  the  disease  progresses,  circulatory  changes  are 
evidenced  by  cyanosis  in  the  finger-tips  and  lips.  Dyspnea  is  easily 
caused  by  slight  exertion  or  coughing.  Hemoptysis  is  exceedingly 
rare  in  children.  If  death  does  not  supervene,  the  affection  may 
appear  elsewhere,  as  in  the  brain,  intestinal  tract,  or  in  the  glandular 
structures. 

Physical  Signs. — These  may  not  differ  from  the  ordinary  broncho- 
pneumonic  type  of  the  disease.  Occasionally  only  are  there  signs 
of  cavity  formation,  or  well-developed  signs  of  bronchial  and  peri- 
tracheal glandular  hypertrophy.  The  latter  signs,  if  obtainable,  are 
of  distinct  diagnostic  importance. 

The  examination  of  the  sputum,  obtained  with  a  laryngeal  swab 
or  from  the  stomach  contents,  urine,  and  feces,  may  reveal  the  pres- 
ence of  tubercle  bacilli. 

Chronic  Pulmonary  Tuberculosis. 

This  form  is  rarely  seen  under  five  years  of  age.  In  the  cases 
that  have  come  under  our  observation,  the  tuberculous  process  was 
extremely  diffuse  in  character.  The  physical  signs  do  not  markedly 
differ  from  those  of  the  adult  type. 

Progressive  loss  of  weight,  night-sweats,  extreme  anemia  with 
high  leukocytosis,  and  frequent  attacks  of  gastroenteritis  are  the 
symptoms  which  finally  precede  death. 

At  any  age  the  pleura  may  become  involved  in  the  tuberculous 
process,  and  an  empyema  result.  The  pus  in  these  cases  is  thinner 
and  more  watery  in  consistency,  and  only  rarely  can  the  tubercle 
bacilli  be  isolated.  These  cases  do  not  tend  to  recovery;  further  lung 
involvement  takes  place,  and  death  often  results  with  meningeal 
symptoms. 


326 


DISEASES  OF  CHILDREN. 


Course. — The  course  of  the  disease  in  early  life  varies  with  the 
form.  There  is  a  latent  form  in  which  the  characteristic  features  are 
irregular  fever,  rapid  emaciation,  and  late  pulmonary  signs.  The 
affection  runs  a  speedy  course,  terminating  sometimes  in  a  few 
days  to  a  fortnight.  The  child  with  the  bronchopneumonie  or  the 
more  usual  variety  may  live  several  weeks.  In  exceptional  cases  the 
patient  has  lived  six  months.  The  chronic  form,  under  favorable 
circumstances,  such  as  the  modern  sanatorium  treatment  gives  a  more 
favorable  prognosis;  that  is,  there  is  a  tendency  toward  arrest  of 
the  process. 


Fig.  91. — Clubbed  fingers  in  chronic  pulmonary  tuberculosis. 

Acute  Miliary  Tuberculosis. 

This  is  an  acute  general  infection  with  tubercle  bacilli,  occurring 
at  any  period  of  childhood.  As  a  rule,  it  is  secondary  to  some  primary 
focus  in  the  body,  which  may  have  been  dormant  for  some  time. 

Etiology. — Measles,  whooping-cough,  and  tuberculous  lymph 
nodes  are  the  exciting  causes.  The  disease  occurs  quite  commonly  in 
early  life,  especially  the  meningeal  form  or  tuberculous  meningitis. 
McCrae  had  forty-three  cases  of  generalized  miliary  tuberculosis  in  417 
autopsies  on  tuberculous  individuals,  among  these  were  fifty-five 
children.  The  meninges  were  involved  in  twenty-one,  and  the  tho- 
racic lymph  nodes  in  thirty-three  cases. 

Two  forms  of  the  disease  are  recognized — the  general  and  local — 
based  upon  the  symptoms. 

In  the  general  form  the  symptoms  in  the  early  stages  are  such  as 
to  simulate  beginning  typhoid.  There  is  irregular  fever  with  no 
characteristic  curve  malaise,  loss  of  appetite,  slow  emaciation  at  first, 


TUBERCULOSIS.  327 

becoming  more  marked  as  the  disease  progresses.  The  pulse  is  in- 
creased out  of  proportion  to  the  temperature.  Rapid,  shallow 
breathing  is  later  followed  by  the  Cheyne-Stokes  type  as  the  disease 
progresses,  or  if  meningeal  symptoms  intervene.  Vomiting  is  often 
an  early  symptom. 

The  spleen  is  enlarged  almost  invariably  and  the  liver,  too,  is 
often  increased  in  size.  A  disturbing  slight  cough  is  generally  present. 
The  urine  contains  traces  of  albumin  and  hyahn  casts,  and  occasion- 
ally tubercle  bacilli  can  be  found.  Inoculation  tests  from  the  blood 
may  confirm  the  diagnosis.  The  younger  the  child  the  more  often 
does  the  meningeal  form  bring  on  a  rapid  termination.  Delirium, 
stupor,  and  coma  denote  cerebral  involvement.  The  usual  course  is 
from  three  to  six  weeks.     The  prognosis  invaiiably  is  hopeless. 

Differential  Diagnosis. — The  Widal  test  and  the  more  typical  tem- 
perature curve,  with  the  characteristic  eruption,  plus  the  relative 
increase  in  the  mononuclear  elements  in  typhoid,  must  be  depended 
upon  to  distinguish  this  form  of  tuberculosis  from  typhoid,  although 
this  is  sometimes  extremely  difficult.  In  miliary  tuberculosis,  besides 
the  tuberculin  test,  an  ocular  examination  may,  especially  in  the  later 
stages,  show  tubercles  in  the  choroid,  or  fluid  withdrawn  from  the 
spinal  canal  may  show  tubercle  bacilli. 

Local  Manifestations. — Miliary  involvement  of  the  lungs  usually 
occurs  after  measles  or  whooping-cough,  or  is  secondary  to  a  broncho- 
pneumonic  process.  The  physical  signs  offer  no  help  in  differentiation. 
The  diagnosis  in  children  is  extremely  difficult  until  the  disease  has 
progressed  to  some  other  structure,  as  the  brain,  when  more  character 
istic  symptoms  are  obtainable. 

Tuberculous  Meningitis. 

The  tubercle  bacilli  spread  from  some  focus  of  infection  through 
the  lymph  channels  or  blood  current  to  the  meninges,  and  usually  form 
an  eruption  of  miliary  tubercles  at  the  base  of  the  brain,  spreading  up 
to  the  vessels  in  the  fissure  of  Sylvius.  An  inflammatory  exudate 
is  almost  invariably  found  in  the  space  between  the  optic  chasm  and 
the  peduncles.  The  exudate  is  yellowish-green  in  color,  tenacious 
and  adherent  to  the  pia  mater.  The  ventricles  are  more  or  less 
distended  wath  fluid,  in  some  instances  forming  a  distinct  internal 
hydrocephalus.  The  ependyma  if  carefully  "emoved  Is  found  to  be 
rough,  edematous,  and  may  be  infiltrated  with  tubercles.  The  pia 
mater  is  injected  with  a  serofibrinous  or  seropurulent  infiltrate. 
Not  infrequently  the  tubercles  are  seen  in  the  choroid  plexus.     Occa- 


328  DISEASES  OF  CHILDREN. 

sionally  there  is  only  a  slight  amount  of  exudate,  and  the  infection  is 
found  to  be  localized  in  the  form  of  one  or  more  nodules,  some  the  size 
of  hickory-nuts  which  are  known  as  solitary  tubercles  of  the  brain. 

Etiology. — Tuberculous  lymph  nodes  which  have  become  diseased 
as  a  result  of  the  acute  infectious  diseases,  especially  peitussis  and 
measles,  play  the  principal  role  in  the  causation.  A  latent  tuberculous 
focus  may  set  free  the  tubercle  bacilli  into  the  blood  stream.  A  tuber- 
culous osteitis  or  an  infection  in  the  uropoietic  system  may  be  respon- 
sible for  the  meningeal  involvement.  A  number  of  cases  seem  to  be 
traceable  to  a  chronic  otitis  media.  Unsanitary  surroundings,  espe- 
cially in  a  tuberculous  environment,  predispose  to  the  disease.  On  the 
other  hand,  it  occurs  among  the  well-to-do,  and  may  attack  a  child  that 
has  been  considered  exceptionally  healthy.  It  commonly  occurs 
below  the  age  of  five  years.  Infants  of  five  months  have  been  reported 
who  have  died  of  the  disease.  (Rilliet).  In  Koplik's  series  of  fifty- 
two  cases,  eleven  were  less  than  one  year  old,  while  the  average  age 
was  slightly  over  four  years. 

Symptomatology. — It  is  impossible  to  give  a  typical  de«!cription 
of  the  symptoms  of  this  disease,  so  varied  are  its  manifestations. 

The  prodromal  symptoms  usually  come  on  gradually  and  insidi- 
ously. A  previously  healthy  child  becomes  irritable,  morose,  and 
refuses  to  play.  Lassitude,  coated  tongue,  loss  of  appetite  and  occa- 
sional vomiting  are,  as  a  rule,  attributed  to  digestive  disturbances. 
If  the  child  is  old  enough,  headache,  dull  in  character,  is  complained  of. 
Progressively  the  symptoms  grow  more  marked  until  signs  of  cerebral 
irritation  appear.  Occasionally  the  onset  is  abrupt  with  fever,  vomit- 
ing,   and  pressure  symptoms. 

The  diagnosis  may  not  be  suspected  until  the  child  refuses  to 
leave  the  bed.  The  pulse  rate  in  infants  is  usually  increased;  in 
older  children  it  may  be  irregular  in  character.  Vomiting  occurs 
irregularly  and  with  no  regard  to  the  food  ingested.  The  temperature 
is  not  high,  rarely  over  101°  F.  and  may  be  normal  during  the  morning 
hours.  The  mentality  is  dulled  and  the  child  is  aroused  with  diffi- 
culty. The  food  is  taken  without  protest  or  interest.  Infants 
may  show  increased  tension  by  a  bulging  fontanel.  A  high-pitched 
scream,  which  if  once  heard  is  easily  recognized  and  known  as  the  hy- 
drocephalic cry,  often  accompanies  the  headache  which  may  now. 
be  intense.  Except  in  infants  the  abdomen  becomes  flat  or  sunken 
in  the  later  stages,  forming  the  so-called  scaphoid  abdomen.  Con- 
stipation is  the  rule.  Rigidity  of  the  muscles  of  the  neck  may  be  noted, 
but  distinct  retraction  may  never  occur  or  only  in  the  final  stages. 
There  may  now  supervene  irregular  or  associated  ataxic  movements. 


TUBERCULOSIS. 


329 


The  respirations  are  slow  and  irregular,  with  the  inspiration  prolonged 
and  sighing.  The  pupils  may  be  unevenly  contracted  and  react 
slowly  or  not  at  all  to  light.  Nystagmus  may  be  an  early  symptom, 
while  conjunctivitis,  strabismus,  and  ptosis  usually  appear  in  the  final 
stage.  Marked  apathy  with  delirium  and  coma  supervene.  Occa- 
sionally convulsions  ma}*  occur.  The  pupils  are  now  almost  constantly 
dilated.  The  extremities  are  rigid  or  spastic,  although  paralyses,  mono- 
plegic  or  hemiplegic  in  type,  may  appear  before  the  terminal  stage. 


m^Bk       ^^  ^^ 

> 

""^Ij 

Fig.  U2. — a.  Tuberculous  meningitis;  patient  semi-comatose;  b,  tuberculous 
meningitis;  last  stages,  coma  absolute. 

The  respirations  tend  now  to  the  Cheyne-Stokes  type.  The  final 
stage  is  usually  known  by  the  frequent  convulsive  seizures.  The 
emaciation  is  now  rapid,  the  pulse  becomes  small  and  irregular  until 
the  agonal  stage.  The  eyes  are  sunken.  Edema  of  the  lungs  may  be 
found  on  physical  e.xamination.  The  rigidity  of  the  neck  is  supplanted 
by  parah'ses  in  various  parts  of  the  body.  Examination  of  the  fundus 
usually  shows  an  optic  neuritis.  The  urine  and  feces  may  be  involun- 
tarily passed.  The  temperature  toward  the  end  may  rise  to  105° 
or  106°  F.,  or  there  may  be  a  sudden  drop  to  subnormal. 

The  reflexes  are  usually  inhibited  in  this  stage.  Kernig's  sign 
and  the  Babinski  reflex  are  present  in  about  50  per  cent,  of  the  cases. 
MacEwen's  sign,  or  a  tympanitic  note  on  percussion  over  the  ventricles, 
is  obtained  in  those  cases  in  which  there  is  an  internal  hydrocephalus. 
If  obtained  in  children  over  two  years  of  age,  it  is  of  value  in  establish- 
ing the  diagnosis. 


330  DISEASES  OF  CHILDREN. 

Lumbar  puncture  is  of  great  importance  in  making  the  diagnosis 
and  sometimes  is  the  only  practical  method  of  making  the  specific 
diagnosis.  In  this  form  of  meningitis  the  fluid  frequently  flows  out 
under  increased  pressure;  it  usually  is  clear  and  contains  a  greater 
amount  of  protein  than  normal, 

Fehling's  solution  occasionally  is  reduced  by  the  fluid.  If  the 
proper  technic  is  followed,  the  presence  of  tubercle  bacilli  can  be 
demonstrated,  although  such  expert  labor  should  be  placed  in  the 
hands  of  a  trained  pathologist.  Inoculation  experiments  into  animals 
may  also  be  made  for  confirmation.  Mononuclear  cells,  sometimes 
over  90  per  cent.,  are  present  in  the  fluid. 

Course. — The  duration  is  usually  from  three  to  four  weeks. 
Occasionally  there  are  periods  of  apparent  improvement,  which  may 
give  rise  to  a  false  hope  of  recovery.  On  the  other  hand,  cases  have 
remained  under  our  observation  for  many  weeks  with  slow  and  pro- 
gressive emaciation,  finally  terminating  fatally. 

Diagnosis. — The  slow  onset,  the  lack  of  hyperesthesia,  the  slower 
pulse  and  respiration,  and  the  type  of  temperature  curve,  with  the 
aid  of  lumbar  puncture,  are  the  only  definite  means  of  differentiation 
from  the  cerebrospinal  type. 

Some  intracranial  diseases  may  in  their  incipiency  lead  to  con- 
fusion unless  the  characteristic  symptoms  of  a  meningitis  are  sought 
for. 

Prognosis. — Although  there  have  been  several  reported  cures  in 
cases  in  which  tubercle  bacilli  were  found  after  repeated  lumbar 
punctures,  the  disease  must  be  regarded  as  quite  hopeless. 

Treatment. — Quiet  and  rest,  with  bromids  for  the  relief  of  the 
nervous  symptoms,  and  lumbar  puncture  for  the  relief  of  intra- 
cranial pressure,  with  frequent  repetition  of  this  procedure  if  followed 
by  amelioration  of  the  symptoms,  are  indicated.  The  diet,  usually 
liquid,  is  taken  in  a  bottle  or  may  be  given  by  gavage.  lodid  of 
potash  and  inunctions  of  mercury  have  proved  valueless  in  our  hands. 

Tuberculous  Peritonitis. 

Tuberculous  peritonitis  is  a  comparatively  rare  affection,  although 
this  variety  of  peritonitis  is  more  frequently  seen  in  childhood  than 
the  non-tuberculous  forms,  and  a  diagnosis,  first  as  to  the  condition 
itself,  and  then  as  to  its  particular  variety,  is  of  importance  because 
of  the  direct  bearing  on  the  prognosis  and  surgical  treatment.  The 
peritoneum  may  become  involved  from  a  tuberculous  focus  in  any 
part  of  the  body.     The  disease  is  nearly  always  secondary  and  the 


TUBERCULOSIS. 


331 


infection  is  carried  through  the  lymphatics  or  blood  stream.  Bovaird 
in  125  cases  of  general  tuberculosis  found  the  peritoneum  involved  in 
7  per  cent. 

From  an  anatomical  standpoint  four  forms  are  usually  recognized. 
Miliary,  miliary  with  ascites,  the  ulcerative,  and  the  fibrous  variety. 

The  miliary  form  is  met  with  in 
cases  of  general  infection.  It  is  practi- 
cally impossible  to  make  antemortem 
diagnosis  of  this  form.  The  tubercles 
are  found  scattered  over  the  peritoneum 
and  intestines  in  large  or  small  numbers. 
Adhesions  form,  binding  the  viscera  to 
themselves,  to  the  neighboring  organs, 
and  the  abdominal  wall.  On  opening 
the  abdominal  cavity  a  serous  or 
seropurulent  fluid  is  found.  The  peri- 
toneum is  clouded  and  streaked  with 
lymph.     In  older  case.^  adhesions  form. 

The  Ulcerative  or  Caseating 
Form. — Postmortem  findings  in  this 
variety  show  caseating  foci  in  the  peri- 
toneum. Lymph  or  pus  takes  the  place 
of  ascitic  fluid.  The  intestinal  coils  are 
matted  with  fibrinoplastic  deposits.  The 
abdominal  wall  may  also  be  found  ad- 
herent to  the  intestines.  Tuberculous 
masses  are  found  scattered  over  the 
parietal  and  visceral  peritoneum,  while 
in  some  cases  ulcerations  occur.  The 
glands  are  usually  greatly  enlarged,  and 
may  be  found  in  sacculations  filled  with 
purulent  fluid.  Fistulous  tracts  may 
occur  and  perforate  at  or  near  the 
umbilicus. 

The  fibrous  form  rarely  gives  evi- 
dences of  an  effusion.  There  is  an  abundance  of  lymph  on  a  thick- 
ened peritoneum,  studded  with  mihary  tubercles.  The  peritoneal 
cavity  may  be  completely  obliterated  by  the  dense  matting  and  firm 
adhesions.  Rolls  of  omentum  are  occasionally  seen,  covered  with 
fibrous  tissue.  The  intestines  themselves  adhere  to  each  other. 
The  characteristic  of  this  form  is  a  tendency  to  the  formation  of 
cicatricial  tissue. 


Fig    U3. — The  ascitic  form  of 
tuberculous  peritonitis. 


332  DISEASES  OF  CHILDREN. 

Symptomatology  of  the  Special  Forms. —  Ascitic  Form. — The 
symptoms  may  be  very  insidious.  There  is  a  slow  but  steady 
increase  in  the  size  of  the  abdomen,  and  constipation  alternates 
with  diarrhea.  There  may  be  vomiting,  the  appetite  is  capricious 
or  lost.  Careful  examination  may  now  elicit  fluid  in  the  abdominal 
cavity. 

The  superficial  veins  over  the  abdomen  and  lower  chest  are 
prominent.  There  is  an  evening  rise  of  temperature,  and  progressive 
emaciation  is  noted.  Rectal  examination  may  disclose  peritoneal 
nodules  and  enlarged  mesenteric  glands.  An  acute  form  is  occasionally 
seen  in  which  the  symptoms  simulate  an  inflammation  of  the  small  and 
large  intestines.  The  fever  is  quite  high,  the  abdomen  rapidly  becomes 
distended  with  fluid.     The  prognosis  is  better  in  the  insidious  form. 

Ulcerative  Form. — The  symptoms  are  those  of  various  grades 
of  enteritis.  There  is  vomiting,  constipation  or  diarrhea,  abdominal 
pain,  loss  of  appetite,  with  occasionally  bloody  stools.  The  fever  is 
quite  high,  irregular  in  type  with  occasional  sweating,  especially  on 
exertion,  and  considerable  prostration. 

Percussion  shows  areas  of  dullness  or  flatness,  alternating  with 
areas  of  tympany^  Bimanual  rectal  examination  may  give  strong 
evidence  of  the  matted  condition  of  the  intestines.  Occasionally 
the  stools  contain  blood.  Pus  may  be  discharged  through  openings 
near  the  umbilicus.  Emaciation  is  extreme,  and  the  end  comes 
through  asthenia. 

Fibrous  Variety. — The  symptoms  come  on  very  gradually 
with  some  colicky  pains  in  the  abdomen.  The  bowels  are  usually 
constipated.  There  is  some  distention  of  the  abdomen.  Nausea  and 
vomiting  or  symptoms  of  obstruction  may  lead  to  a  careful  examina- 
tion of  the  abdomen,  and  the  masses  or  rolls  of  omentum  with  some 
intraabdominal  fluid  may  assist  in  establishing  the  diagnosis. 

Diagnosis. — A  child  between  the  ages  of  one  and  six  years  who  has 
lived  in  an  environment  of  tuberculosis  or  whose  vitality  has  been 
lowered  by  an  infectious  disease,  and  who  is  languid,  peevish,  and  has 
an  evening  rise  of  temperature  with  some  enlargement  of  the  abdomen, 
should  be  carefully  examined  for  tuberculous  peritonitis.  The  child 
may  present  the  phthisical  habitus  or  only  appear  to  have  lost  some 
flesh.  The  skin  is  almost  constantly  dry  and  harsh.  Passing  the 
hand  lightly  over  the  abdomen,  subcuticular  nodules  about  the  umbili- 
cus are  often  felt.  Fluctuation  may  be  readily  made  out,  or  a  sus- 
picion of  fluid  only  may  be  found  on  palpation  and  percussion.  Bi- 
manual rectal  examination  in  the  semirecumbent  position  should  now 
be  made  to  confirm  the  presence  of  fluid  and  to  further  ascertain  the 


TUBERCULOSIS.  333 

condition  of  the  intestines,  whether  they  are  free  or  bound  by  a  fibrino- 
plastic  exudate.  One  accustomed  to  the  normal  conditions  as  found 
by  the  examining  finger  in  children  will  appreciate  the  changes  pro- 
duced by  a  plastic  exudate,  and  may  furthermore  feel  hypertrophied 
mesenteric  lymph  nodes  and  a  band  of  adhesions  running  transversely 
across  the  abdomen.  If  the  process  has  so  far  advanced  that  rolls  of 
omentum,  or  agglutinated  masses  of  mesentery  and  intestine  have 
formed,  palpation  over  the  abdomen  and  the  finger  in  the  rectum 
will  readily  reveal  the  presence  of  these  tumors.  The  abdomen  may 
then  appear  flat  or  gas-distended,  and  Thomayer's  sign  of  dullness  on 
percussion  on  the  left  side  of  the  abdomen,  with  a  tympanitic  note  on 
the  right  side,  may  be  obtained;  in  this  latter  condition  fluid  is  rarely 
made  out  before  operation,  and  only  small  quantities  are  seen  on 
opening  the  abdomen. 

In  the  early  stages  of  the  ascitic  form  we  should  if  possible  exclude 
circulatory,  renal  and  hepatic  disturbances,  and  abdominal  growths. 
The  general  nutrition  may  still  be  fairly  good.  The  fluid  readily  gravi- 
tates to  the  dependent  section  on  change  of  position.  Corrobora- 
tive evidence  may  be  obtained  by  finding  Marfan's  symptom,  that 
is,  the  presence  of  pleuritic  friction  rales  at  the  base  of  the  lungs, 
sometimes  associated  with  small  exudations  into  the  pleura.  Pain 
is  rarely  obtained  on  palpation,  but  indefinite  colicky  pains  are  com- 
plained of.  If,  coupled  with  the  above  symptoms,  the  skin  is  harsh 
and  dry,  and  subcuticular  nodules  are  present  over  the  abdomen,  the 
diagnosis,  now  fairly  certain,  should  be  confirmed  by  laboratory  and 
tuberculin  tests.  The  frequent  use  of  the  thermometer  showing  pre- 
dominating small  evening  rises  and  the  presence  of  large  numbers  of 
lymphocytes  always  tend  in  favor  of  a  tuberculous  process.  In  a 
tuberculous  peritonitis  the  mononuclear  leukocytes  are  generally 
increased.  Cytological  study  of  the  tapped  ascitic  fluid  may  also  assist 
in  confirming  the  diagnosis.  The  diagnosis  in  the  first  form  is  not 
always  certain  without  further  tests,  and  even  the  last-described  variety 
may  cause  confusion. 

If  a  chronic  peritonitis  of  the  tuberculous  variety  is  suspected, 
a  very  thorough  examination  of  the  entire  body  should  be  made  for 
possible  tuberculous  disease  in  other  organs  not  only  to  confirm  the 
diagnosis,  but  to  determine  what  shall  be  the  character  of  the  treat- 
ment and  the  prognosis.  For  if  the  lungs  are  involved  and  the  spleen 
and  liver  are  enlarged,  general  miliary  tuberculosis  is  in  all  probability 
present,  and  the  patient  is  beyond  the  hope  of  recovery.  Whether  or 
not  the  peritoneal  process  is  tuberculous  may  be  confirmed  either  by 
the  skin-inoculation  test  of  Von  Pirquet,  by  the  Moro  reaction  (i.e.,  a 


334 


DISEASES  OF  CHILDREN. 


50  per  cent,  tuberculin  ointment)  or  by  the  Calmette  test;  but  this  is 
not  recommended  if  there  is  any  possibility  of  corneal  involvement. 
The  catheterized  urine  may  be  centrifuged  for  the  presence  of  tubercle 
bacilli,  or  inoculation  tests  can  be  made  with  guinea-pigs. 

Treatment. — The  trend  of  opinion,  buoyed  up  by  some  successful  re- 
sults in  recent  years,  tends  toward  operation  in  all  cases  of  tuberculous 
peritonitis,  especially  as  the  operation  is  comparatively  simple  and  not 
dangerous  to  life.  If  more  regard  had  been  paid  to  the  general  ex- 
amination and  only  selected  cases  operated  upon,  the  statistics  would 
have  been  steadily  in  favor  of  operation.  The  ascitic  form  of  local- 
ized tuberculous  peritonitis  does  well  under  laparotomy,  the  plastic 
form  rarely  does  well;  fistulse  are  apt  to  form,  and  the  lungs  frequently 
show  early  involvement  following  the  laparotomy.  Again,  if  the  di- 
agnosis can  be  made  early  in  the  ascitic  form  non-operative  interference 
may  be  counseled  provided  the  circumstances  are  such  that  all  the 
anvantages  accruing  from  life  at  the  seashore,  rest  and  nutritious  food 
are  possible.  Otherwise  the  child  should  be  watched,  and  if  the  exudate 
is  on  the  increase  operation  should  be  recommended.  A  life  in  the 
fresh  air,  confinement  to  bed  while  an  active  process  is  going  on, 
food  high  in  proteids  and  fats,  with  the  addition  of  cod-liver  oil  and 
the  syrup  of  the  iodid  of  iron  are  indicated  after  laparotomy,  and  for 
the  inoperable  cases. 


Bone  and  Joint  Tuberculosis. 

(Caries  of  Bone.) 

This  affection  is  the  result  of  the  invasion 
of  tubercle  bacilli  in  the  spongy  portion  of 
the  bone.  Usually  beginning  as  a  single  focus 
it  spreads  and  often  involves  the  whole  epi- 
physis. Tubercles  are  formed  which  later 
may  degenerate,  forming  many  necrotic  areas 
which  may  merge  to  form  a  caseating  area. 
Granulation  tissue  is  found  at  the  periphery. 
In  some  instances  a  sequestrum  forms  or  an 
abscess  results.  The  joints  are  infected 
through  the  cartilage,  and  the  disease  rapidly 
spreads  to  the  synovial  membrane  where 
ulcerations  form.  When  the  cartilage  be- 
comes   detached,    destruction   begins    in   the 

bare  bone.     In  this  way  deformities  so  common  in  and  about  the 

joints  are  produced. 


Fig.  94 

dactylitis 


Tuberculous 


TUBERCULOSIS. 


335 


Etiology. — The  infectious  diseases,  especially  measles  and  scarlet 
fever,  are  probably  more  often  the  direct  cause  of  tuberculous  joint 
diseases  than  traumatism.  Any  devitalizing  disease,  however,  must 
be  considered  as  a  factor.  The  affection  is  extremely  rare  in  infants. 
After  the  third  year  it  is  distinctly  a  disease  of  childhood. 

Tuberculosis  of  the  Vertebrae. 


(Pottos  Disease;  Caries  of  the  Spine;  Spondylitis.) 

This  affection  is  the  result  of  a  tuberculous  osteitis  in  the  spongy 
portion  of  the  bodies  of  the  vertebra. 

It  is  extremeh'  common  in  early  childhood,  and,  according  to 
Taylor,  more  than  half  the  cases  occur  under  six  years  of  age.  The 
dorsal  region  is  most  often  affected; 
the  cervical  less  commonly. 

Diagnosis. — If  careful  physical 
examinations  were  oftener  made  with 
the  child  completely  undressed,  the 
diagnosis  would  more  frequently  be 
reached  in  the  early  stages.  The 
abnormalities  which  should  attract 
attention  are  the  rigidity  of  the 
spine,  and  in  walking  a  deficient 
mobility  of  the  spinal  column  when 
tested  by  the  examiner.  Deformities 
due  to  necrosis  of  the  bone  will  be 
apparent  on  observation,  often  form- 
ing the  familiar  humpback.  The 
peculiar  attitude  and  gait  assumed 
may  attract  attention,  even  before 
the  child  is  undressed. 

In  cervical  Pott's  disease, 
wry-neck  may  be  the  first  symptom 
complained  of.  The  differential 
diagnosis  from  other  forms  of  torticollis  is  sometimes  very  difficult. 
The  slower  onset,  the  posture,  and  the  general  muscular  fixation  serve 
to  distinguish  it. 

Dorsal  Pott's  disease  is  distinguished  by  the  erect  military 
gait,  the  lateral  deviation,  with  a  bony  deformity,  which  can  be 
palpated  and  usually  easily  seen. 

Lumbar  Pott's  Disease. — Here  the  attitude  of  lordosis  should 


Fig.  95. — TotticoUis,  duo  to  cervical 
Pott's  disease.    (Bradford  and  Lovett.) 


336 


DISEASES  OF  CHILDREN. 


attract  attention,  especially  if  accompanied  with  deviation  to  one  side, 
and  a  careful  abnormal  gait.  Hyperextention  of  the  leg  in  the  prone 
position  elicits  the  sign  of  psoas  contraction. 

Paralysis. — This  may  occur 
at  any  time  in  tuberculous  spinal 
disease,  although  as  a  rule  it  occurs 
as  one  of  the  later  symptoms. 

The  patellar  reflexes  are  in- 
creased, ankle  clonus  may  be  pres- 
ent, and  the  pain,  if  absent  before, 
is  now  present  or  increased  in 
severity. 

A  RACHITIC  SPINE  is  often 
mistaken  for  Pott's  disease.  The 
curve,  however,  is  rounded  and 
the  spine  is  supple.  If  the  child 
is  raised  with  the  hands  of  the 
examiner  in  the  axilla  the  curva- 
ture tends  to  disappear.  Other 
bony  changes  or  the  symptoms  of 
rickets  may  be  present.  The  de- 
formity in  Pott's  disease  does  not 
disappear  when  the  child  is  raised 
or  is  in  the  prone  position. 

Treatment. — This  is  mainly 
orthopedic  and  involves  the  use 
of  apparatus  to  promote  spinal 
rest  (Fig.  98)  and  the  correction 
and  prevention  of  deformities. 
The  medical  treatment  encompasses 
dietetics  and  hygienic  manage- 
FiG.  96  — Dorsal  Pott's  disease.  ment. 


Tuberculous  Disease  of  the  Hip. 

(Hip- joint  Disease;  Morbus  Coxcb;  Coxalgia.) 

This  affection  is  due  to  a  tuberculous  osteitis  of  the  head  of  the 
femur,  of  the  acetabulum,  or  both.  The  disease  usually  begins 
gradually,  the  parents  first  noticing  a  limp.  Night  cries  occur,  but 
pain  is  a  very  variable  symptom.  The  attitude  assumed  is  one  with 
a  little  flexion  of  the  knee  of  the  affected  side  and  a  slight  tilting  of  the 
pelvis.     In  later  stages  of  the  disease  much  can  be  learned  by  testing 


TUBERCULOSIS. 


337 


the  child  for  freedom  of  motion,  picking  up  objects,  mensuration,  pain 
and  swelling.  The  classical  symptoms  upon  which  a  diagnosis  can  be 
based  with  certainty  are  limit  of  motion,  muscular  spasm,  pain, 
swelling,  attitude,  shortening  and  atrophy  of  muscle.  The  X-rays 
and  the  tuberculin  tests  may  be  required  in  difficult  cases. 


Fiu.  97. — Lumbar  Pott's  disease. 


Treatment. — Immobilization  and  protection  of  the  joint  by  casts, 
traction,  and  later,  braces;  a  life  in  the  open  air  and  good  food  do 
much  to  assist  the  orthopedic  measures.     Osteotomy  and  excisions 
are  performed  only  in  desperate  cases. 
22 


338 


DISEASES  OF  CHILDREN. 


Tuberculous  Disease  of  the  Knee. 

{Gonitis  Tuberculosa;  White  Swelling.) 

The  epiphyses  are  nearly  always  primarily  involved.  It  is  most 
commonly  observed  in  children,  and,  after  the  spine  and  hip  involve- 
ment, it  occurs  most  frequently. 

The  diagnosis  is  usually  quite 
readily  made,  as  the  knee-joint 
easily  lends  itself  to  examination. 
Swelling,  with  lameness  which  may 
be  intermittent,  are  the  first 
diagnostic  symptoms.  Stiffness 
and  pain  follow.  Muscular  spasm 
on  passive  motion  may  be  observed. 
The  knee  may  be  held  in  a  posi- 
tion of  flexion.  Infectious  synovitis 
is  distinguished  by  the  more  rapid 
onset,  temperature,  and  signs  of 
localized  inflammation. 

Chronic  synovitis  is  very  slow 
in  its  course  and  is  not  accom- 
panied by  much  lameness  or  pain. 
Sometimes  crepitus  may  be  ob- 
tained. Eventually  a  true  tumor 
albus  may  result.  The  X-rays, 
tuberculin,  and  inoculation  tests 
may  be  made  if  necessary. 

Treatment. — The  medical 
treatment  does  not  differ  from  that 
of  tuberculosis  elsewhere.  The 
joint  should  be  encased  in  a  splint 

Fig.  <J8.-Infant  with  Pott's  disease  on    which  will  prevent  joint  motion  of 
a  Bradford  frame.  the  knee  and  foot. 

Treatment  of  Tuberculosis  in  General. 

Prophylactic. — There  are  but  few  diseases  in  which  prophylaxis 
can  accomplish  so  much  for  the  child  as  in  tuberculosis.  Upon  the 
physician  and  health  officer  the  duty  devolves,  and  it  begins  even 
before  conception.  It  is  largely  a  problem  of  sociology  and  preven- 
tative medicine. 

Laws  which  have  lately  been  passed  in  many  States  prohibiting 
the  sale  of  tuberculous   milk  and   meat,  tenement-house  inspection, 


TUBERCULOSIS.  339 

health-board  notification,  and  the  educational  exhibits  will  all  tend 
to  decrease  the  spread  of  this  disease.  Tuberculous  mothers  should 
not  nurse  their  children  because  of  danger  in  the  close  contact. 

Milk  for  infant  feeding  should  be  obtained  from  tuberculin  tested 
cows,  or  should  have  the  stamp  of  approval  of  a  medical  commission 
as  being  "certified."  Where  this  is  not  possible  the  milk  may  be 
pasteurized. 

The  children  of  tuberculous  parents  should  be  brought  up,  if 
possible,  in  the  country  and  early  trained  to  live  an  outdoor  life. 
Such  defects  as  adenoids  or  carious  teeth  should  be  removed.  They 
should  be  especially  guarded  from  measles  and  whooping-cough. 

School  houses  should  be  so  arranged  that  proper  ventilation  can 
be  obtained  in  rooms  with  ample  air  space  and  sunlight.  Teachers, 
who  as  a  class  are  particualrly  susceptible  to  the  disease,  should  be 
frequently  examined. 

Knofif  has  formulated  the  following  valuable  set  of  rules  for 
school  cMldren: 

Do  not  spit  except  in  a  spittoon  or  a  piece  of  cloth  or  a  handker- 
chief used  for  that  purpose  alone.  On  your  return  home,  have  the 
cloth  burned  by  your  mother  or  the  handherchief  put  in  water  until 
ready  for  the  wash. 

Never  spit  on  a  slate,  floor,  sidewalk,  or  playground. 

Do  not  put  your  fingers  into  your  mouth. 

Do  not  pick  your  nose  or  wipe  it  on  your  hand  or  sleeve. 

Do  not  wet  your  fingers  in  your  mouth  when  turning  the  leaves 
of  books. 

Do  not  put  pencils  into  your  mouth  or  wet  them  with  your  lips. 

Do  not  hold  money  in  your  mouth. 

Do  not  put  pins  in  your  mouth. 

Do  not  put  anything  into  your  mouth  except  food  and  drink. 

Do  not  swap  apple  cores,  candy,  chewing-gum,  half-eaten  food, 
whistles,  bean-blowers,  or  anything  that  is  put  into  the  mouth. 

Peel  or  wash  your  fruit  before  eating  it. 

Never  cough  or  sneeze  in  a  person's  face.  Turn  your  face  to  one 
side  and  hold  a  handkerchief  before  your  mouth. 

General. — Reports  from  the  sanatoria  would  indicate  that  the 
child  over  four  years  of  age  afflicted  with  tuberculosis  in  the  incipient 
stage  has  a  better  prognosis  than  the  young  adult.  This  is  borne 
out  by  our  own  dispensary  cases  which  have  had  but  in  different  oppor- 
tunities, and  still  have  shown  gratifying  results. 

The  diet  for  these  children  should  consist  principally  of  milk, 
eggs,  and  fats;  such  as  butter,  cream,  olive  or  cod-liver  oil,  and  meat 


340  DISEASES  OF  CHILDREN. 

for  older  children.  The  syrup  of  the  iodid  of  iron  should  be  given. 
If  the  appetite  fails  a  change  from  inland  to  seashore  or  vice  versa 
may  be  proposed,  or  if  this  is  not  feasible  the  tincture  of  nux  vomica 
with  the  compound  tincture  of  cardamon  can  be  given  before  meals 
Medication  directed  to  the  disease  itself  is  useless  and  often  harmful. 
In  hopeless  cases  the  symptoms  are  alleviated  as  they  arise. 

The  tuberculin  treatment  is  again  being  tried  in  children's  hos- 
pitals and  with  more  success.  Good  results  are  obtained  in  localized 
conditions  and  some  cases  having  pulmonary  involvement  have  been 
benefited.  The  former  unsatisfactory  results  are  attributable  to  our 
meager  knowledge  of  its  action,  and  probably  to  overdosage,  v>hich 
seemed  to  produce  harmful  results. 

Children  in  whom  the  disease  seems  to  be  arrested,  as  shown  by 
absence  of  temperature  and  increase  in  weight,  are  especially  suitable 
f  )r  the  tuberculin  treatment.  The  injection  in  these  quantities  may 
be  given  twice  a  week  until  a  tolerance  is  reached  when  the  dosage 
may  be  slowly  increased  by  0.1  mg.,  depending  upon  the  effect  produced. 
T2iiFTr  to  -8151777  nig  of  T.  R.  tuberculin  is  given  to  a  child  one  year  old. 
4i7Viy  nig.  for  a  child  five  years  old.  -j-ijV^  mg.  for  a  child  ten  to  twelve 
years  old.  Its  effect  on  the  opsonic  index  should  be  watched,  and  a 
dose  given  every  two  weeks.  If  obtaining  the  opsonic  index  is  not 
feasible,  the  weight  and  general  progress  of  the  child  must  act  as  guides. 


SECTION  VII. 
DISEASES  OF  THE  RESPIRATORY  TRACT. 


CHAPTER  XXV. 
DISEASES  OF  THE  UPPER  RESPIRATORY  TRACT. 

Acute  Rhinitis. 

This  is  quite  commonly  seen  in  infants  and  children,  and  is  due  to 
bacterial  infection  as  a  result  of  a  temporary  or  prolonged  lowered 
resistance.  This  is  made  possible  by  keeping  the  child  in  superheated 
apartments,  sudden  changes  of  temperature,  or  exposing  it  to  direct 
infection  from  a  member  of  the  household.  There  is  at  first  a  constant 
serous  and  later  mucopurulent  discharge  from  the  nares,  with  irri- 
tability, restlessness  in  sleep,  loss  of  appetite,  and  a  slight  temperature. 

In  infancy  the  symptoms  are  of  greater  import  than  in  childhood, 
as  it  may  seriously  interfere  with  nursing  and  thus  add  to  the  lowered 
resistance  through  malnutrition.  Sleep  is  broken,  feeding  rules  are 
interfered  with  and  disturbances  of  the  gastrointestinal  tract  may  re- 
sult. Older  children  complain  of  fullness  in  the  head  and  chilliness. 
Children  who  have  frequent  attacks  of  rhinitis  are  ofttimes  sufferers 
from  adenoids. 

Treatment. — While  rhinitis  is  a  self-limited  disease,  lasting  from 
one  to  two  weeks,  it  should  not  be  left  untreated.  The  infection  may 
spread  to  the  lower  respiratory  tract  and  end  disastrously.  If  pos- 
sible, remove  the  indirect  cause,  as,  for  example,  badly  heated  and 
unventilated  rooms.  The  child  is  best  confined  to  one  room,  especially 
if  there  are  other  children.  Locally  liquid  albolin  with  camphor  gr.  i 
to  the  ounce  may  be  instilled  into  the  nose.  A  solution  of  adrenalin 
chlorid  1  to  5000  in  infants  and  1  to  1000  in  older  children  gives  tem- 
porary relief  before  suckling  and  at  bedtime.  Morse  found  it  neces- 
sary to  introduce  a  small  rubber  catheter  into  each  nostril  in  a  serious 
case  to  enable  it  to  breathe.  Small  supportive  doses  of  strych- 
nia 2Tir  t.i.d.  are  sometimes  necessary  to  assist  the  child  in  ridding 
itself  of  the  infection.  The  ears  should  be  examined  daily,  as  an  otitis 
is  very  likely  to  supervene  by  extension. 

Epistazis. 

Bleeding  from  the  nose  is  not  often  seen  in  infants,  although  not 
uncommon  in  children;  when  it  occurs  in  infants  it  is  usually  a  result 

341 


342  DISEASES  OF  CHILDREN. 

of  adenoids,  syphilitic  rhinitis,  or  an  ulceration  of  the  nasal  mucous 
membrane,  commonly  found  on  the  anterior  and  inferior  portion  of  the 
septum.  Children  are  liable  to  nose-bleed  because  of  their  tendency  to 
acquire  turgidity  of  the  nasal  mucous  membrane.  Traumatism,  ade- 
noids, foreign  bodies,  and  purulent  rhinitis  are  among  the  more  common 
causative  factors,  while  a  nose-bleed  is  also  seen  in  the  course  of  many 
of  the  infectious  and  blood  diseases  of  early  life.  A  history  of  frequent 
epistaxis  should  lead  one  to  think  of  and  examine  for  adenoids,  ulcers,  or 
cardiac  disease. 

Treatment. — Keep  the  child  in  the  upright  position  and  apply 
pressure  with  the  fingers  against  the  septum,  meanwhile  having  an  ice 
application  held  over  the  cervical  spine.  If  bleeding  still  persists 
pack  the  nose  with  cotton  which  has  been  dipped  in  a  1-2000  adrena- 
lin solution. 

As  soon  as  feasible,  make  a  careful  examination  for  the  underlying 
cause.  If  an  ulcer,  cleanse  and  apply  a  20  per  cent,  solution  of  nitrate 
of  silver.  If  adenoids  are  present,  they  must  be  removed;  this  is 
especially  true  in  infants  who  have  frequent  nose-bleed.  Warning 
should  be  given  the  attendant  as  to  the  significance  of  swallowed 
blood  from  a  nose-bleed,  which  may  occasion  unnecessary  alarm  when 
vomited. 

Foreign  Bodies  in  the  Nose. 

In  children,  usually  between  two  and  five  years,  it  is  not  uncom- 
mon to  find  that  they  have  placed  various  objects  in  their  noses.  These 
may  cause  immediate  symptoms  of  annoyance  or  distress  or,  becoming 
lodged,  cause  a  unilateral  nasal  discharge  that  is  persistent.  Closer 
examination  shows  a  partial  or  total  occlusion  of  that  side  of  the  nares, 
a  mucopurulent  discharge,  occasionally  blood-tinged,  and,  with 
some  objects,  an  odor  of  putrefaction.  We  have  removed  peas, 
pearl  buttons,  shoe-buttons,  paper,  and  a  kernel  of  corn. 

Treatment. — Place  the  child  in  a  good  light  and  use  a  small 
nasal  speculum.  The  object  if  in  situ  for  some  time  may  be  covered 
by  mucous  membrane  or  altered  in  appearance  so  as  to  be  unrecogniz- 
able. If  there  is  still  doubt,  a  probe  sHghtly  bent  can  be  inserted 
and  the  obstruction  recognized;  wipe  out  the  discharge  and  with  a 
nasal  forceps,  snare,  or  hook  remove  it.  If  the  object  has  been  recently 
inserted  and  is  not  high  up,  causing  the  child  to  sneeze  by  tickling 
the  opposite  side  has  succeeded  easily  in  effecting  its  dislodgment. 
The  rhinitis  induced  clears  up  rapidly  after  the  offending  material  is 
removed. 


DISEASES  OF  THE  UPPER  RESPIRATORY  TRACT. 


343 


Examination  of  the  Throat  in  Infants. 

A  careful  inspection  of  the  throat  should  be  made  as  part  of  the 
routine  examination  of  the  sick  infant.  Many  attacks  of  fever  and 
illness  in  infants  are  due  to  inflammation  of  the  throat,  such  attacks 
being  not  infrequently  attributed  to 
some  other  cause.  The  principal  reason 
for  such  a  possible  error  lies  in  the  diffi- 
culty in  getting  a  satisfactory  view  of 
the  fauces.  This  is  especially  true  in 
very  young  infants.  The  tongue  is  high 
and  the  soft  palate  and  pillars  of  the 
fauces  low  down,  so  that  it  is  extremely 
difficult  to  get  a  clear  view  of  the  parts. 
Unless  a  satisfactory  view  is  obtained  at 
the  first  attempt  it  becomes  increasingly 
difficult,  if  not  impossible,  to  see  clearly 
at  all.  The  opening  is  so  small  that  a 
little  mucus  produced  by  the  irritation 
of  a  second  or  third  examination  com- 
pletely obstructs  the  view.  In  addition 
to  this  some  milk  is  apt  to  be  regurgitated 
fpom  the  stomach,  and  then  it  is  abso- 
lutely impossible  to  see  the  real  condi- 
tion of  the  mucous  membrane. 

The  writer  has  had  such  difficulty 
at  times  in  satisfactorily  examining  the 
throat  in  young  infants  that  he  has  de- 
vised a  tongue  depressor  for  this  purpose 
(see  Fig.  99).  Most  of  the  tongue  de- 
pressors in  use  are  not  only  too  large,  but 
do  not  have  the  proper  slant  for  the 
infant's  tongue.  As  a  result,  the  back 
of  the  tongue,  not  being  properly  held, 
arches  up  and  obstructs  the  view  of  the 
fauces.  The  depressor  here  presented  is 
small  enough  for  the  youngest  infant's 
mouth,  and  is  intended  to  curve  over 
the  tongue  to  the  base  of  the  epiglottis. 
It  can  likewise  be  used  in  older  subjects.  By  exercising  a  little 
pressure  downward  and  forward  the  parts  will  come  into  clear 
view.     Of  course  the  infant  should  be  properly  held  and  placed  before 


Fig.  99. — Chapin's  tongue 
depressor  (straight). 


344 


DISEASES  OF  CHILDREN. 


a  good  light  (Fig.  101).  When  everything  is  in  readiness  the  left 
hand  is  used  to  steady  the  head  while  the  right  hand  manipulates 
the  depressor.  These  details  will  naturally  suggest  themselves  to  the 
careful  physician  but  are  often  overlooked,  with  the  result  of  unduly 
fretting  the  infant  and  failing  in  the  examination. 

Pharyngitis  and  Tonsillitis  in  Infants. — In  infants,  tonsillitis,  as 
distinct  from  pharyngitis,  is  rare.  The  whole  mucous  membrane 
of  the  pharynx  and  tonsils  is  involved  in  the  inflammation.  The 
tonsils  may  be  somewhat  enlarged  and  are  covered  with  very  fine  pin- 
head  points  of  a  whitish  exudation.  These  points  can  be  recognized 
only  when  the  fauces  are  well  exposed  in  a  good  light.     In  rare  instances 


Fig.  100. — Chapin's  tongue  depressor  (curved). 


the  uvula  is  swollen  and  infiltrated.  The  secondary  forms  of  pharyn- 
gitis seen  in  most  infective  diseases  will  not  be  here  considered.  The 
primary  form  is  apt  to  be  overlooked  from  the  absence  of  symptoms 
referable  to  the  throat,  and  the  inability  of  the  infant  to  call  attention 
to  the  affected  part.  The  swelling  of  the  lymph-glands  of  the  neck, 
so  often  noted  in  diphtheria  and  scarlatina,  is  not  usually  present  in 
primary  pharyngitis.  The  two  most  common  predisposing  causes  of 
primary  throat  inflammation  in  infants  are:  (1)  disordered  stomach 
and  (2)  exposure  to  cold.  The  frequent  mistakes  in  the  feeding  of 
infants,  especially  overfeeding,  produce  an  acid  fermentation  in  the 
stomach.  By  direct  continuity  the  mucous  membrane  of  the  pharynx 
and  mouth  may  become  irritated  and  inflamed.  When  the  latter 
happens  the  temperature  keeps  up  instead  of  subsiding  when  the 
stomach  is  relieved  of  its  contents  by  vomiting  or  by  their  passage 
into  the  bowel.     Exposure  to  cold  is  likewise  a  common  predisposing 


DISEASES    OF    THE    UPPER    RESPIRATORY    TRACT. 


345 


cause.  Many  infants,  especially  among  the  poor,  are  too  warmly 
clad,  especially  about  the  neck  and  chest.  As  a  result  the  skin  is 
constantly  moist.  Such  infants  live  and  sleep  in  overheated  rooms. 
In  these  cases  an  ordinary  exposure  to  the  cold  air  of  draughts  will 
induce  throat  inflammation. 

It  will  be  noticed  that  the  causes  here  given  are  mentioned  as 
-predisposing.     Most,   if  not   all,   forms   of  tonsillar  and  pharyngeal 


Fig.  101 . — Method  of  holding  infant  for  examination  of  the  throat. 


inflammation  are  due  to  the  presence  of  microbes.  In  health  and 
under  good  hygienic  conditions  the  mucous  membrane  of  the  throat 
may  not  be  unfavorably  affected  by  microbes,  but  under  depressing 
conditions,  particularly  when  the  digestive  tract  is  in  an  irritated 
condition,  the  throats  of  infants  are  vulnerable.  It  is  quite  possible 
that  many  impurities  may  likewise  find  their  way  to  the  mouth  and 
throat  by  means  of  dirt\'  fingers  or  objects  which  are  given  to  infants 
as  toys  and  which  quickly  find  their  way  to  the  mouth. 


346  DISEASES  OF  CHILDREN. 

Treatment. — The  treatment  consists  in  removing  the  cause, 
whether  it  be  a  deranged  stomach,  defective  action  of  the  skin,  or 
faulty  hygienic  surroundings.  The  recurrence  of  attacks  of  pharyn- 
gitis in  infants  is  the  most  common  cause  of  postnasal  rhinitis  in 
children.  The  repeated  irritation  induced  by  these  attacks  causes 
hypertrophy  of  the  adenoid  tissue  at  the  vault  of  the  pharynx  which 
is  the  invariable  accompaniment  of  rhinitis  in  the  later  years  of 
childhood. 

The  immediate  treatment  consists  in  opening  the  bowels  with  a 
mild  laxative,  such  as  castor  oil  or  calomel,  followed  by  small  and 
frequent  doses  of  tincture  of  aconite,  one-quarter  to  one-half  a  drop 
every  two  hours.  If  restlessness  is  a  prominent  symptom,  a  grain  of 
phenacetin  may  be  given  every  three  hours  for  a  few  doses.  As  the 
acute  form  of  the  disease  is  self-limited,  it  is  not  well  to  give  drugs 
very  freely,  especially  those  that  tend  to  upset  the  digestion.  The 
importance  of  recognizing  the  condition  consists  in  taking  steps  to 
prevent  its  recurrence. 

Acute  Pharyngitis. 

Definition. — An  acute  inflammation  of  the  pharynx  and  neigh- 
boring structures. 

Etiology. — Sudden  exposure  to  inclement  weather  which  is  dust 
and  germ  laden  predisposes  to  the  affection.  It  is  present  in  the 
early  stages  of  many  of  the  acute  infectious  diseases  and  may  accom- 
pany gastric  disorders.  Exposure  to  chemical  irritants  in  the  form  of 
vapors  which  produce  a  pharyngitis.  Children  with  obstructions  in 
the  respiratory  tract,  especially  adenoid  growths  are  liable  to  repeated 
attacks. 

Symptomatology. — Locally  there  is  seen  a  reddened  congested 
pharynx  with  the  uvula  and  tonsils  sharing  in  the  inflammatory 
process.  The  larynx  and  nasopharynx  may  also  be  involved.  There 
may  be  a  rise  of  pulse  and  temperature,  but  this  is  rarely  high.  The 
child  complains  of  sore  throat  and  difficulty  in  swallowing.  Under 
appropriate  treatment  there  is  a  rapid  subsidence  of  symptoms. 

Diagnosis. — With  high  temperature  and  vomiting  scarlet  fever 
must  be  kept  in  mind.  Measles  will  show  the  presence  of  Koplik's 
spots,  while  a  diphtheritic  process  will  show  a  beginning  membrane 
and  give   a  positive   culture. 

Treatment. — Prophylactic  treatment  resolves  itself  into  the  re- 
moval of  any  obstructions  to  proper  breathing  and  the  maintenance  of 
proper  resistance  against  infections. 

Locally. — Cold  compresses  applied  every  half-hour.     Mild    anti- 


DISEASES  OF  THE  UPPER  RESPIRATORY  TRACT.        347 

septic  gargles  for  older  children,  such  as  the  Liq.,  antisepticus  alka- 
linus  N.F.  or  Dobell's  solution,  one  part  to  eight  of  water  will  suffice 
if  used  every  two  hours. 

Constitutional. — An  initial  laxative,  such  as  the  citrate  of  magnesia 
or  calomel,  should  be  prescribed.  If  there  is  high  temperature  and 
much  discomfort  phenacetin  with  salol  2  grains  of  the  former  to  1| 
grains  of  the  latter  for  a  five-year-old  child  will  be  efficacious.  The  diet 
should  consist  of  cool  demulcent  preparations,  such  as  oatmeal  or 
barley  gruel,  junket  or  ice-cream. 

Acute  Follicular  Tonsillitis. 

(Acute  Amygdalitis.) 

This  is  a  self-limited  disease  of  short  duration,  usually  bilateral, 
with  constitutional  symptoms  and  a  marked  local  infective  process 
involving  the  tonsillar  crypts  and  the  entire  glandular  structure. 

Etiology. — Children  with  rheumatic  tendency  or  of  a  strumous 
type  are  prone  to  acute  attacks;  those  with  chronically  enlarged  ton- 
sils being  particularly  susceptible.  In  these  latter  cases,  slight  exposure 
to  cold  often  brings  on  an  attack.  One  infection  predisposes  to  a 
second,  presumably  because  of  the  presence  of  bacteria  in  the  crypts 
or  their  accessibility  to  the  tonsil  through  the  mouth  and  nose. 

Symptomatology. — The  onset  of  tonsillitis  is  sudden;  a  chill  or 
chilly  sensations  often  being  the  first  evidence.  This  may  be  followed 
by  marked  prostration,  malaise,  and  vomiting.  The  temperature 
is  high,  frequently  rising  to  104°  or  105°  F.  At  first  the  tonsils  and 
soft  palate  are  reddened  and  swollen,  and  in  a  few  hours  cream-colored 
isolated  spots  appear  on  the  tonsil  plugging  the  mouths  of  the  crypts. 
These  spots  are  about  the  size  of  a  pin-head,  though  at  times  they 
coalesce,  forming  a  pseudomembrane  which  can  be  easily  wiped  off 
with  a  swab  without  producing  a  denuded  or  bleeding  area.  The 
membrane  does  not  spread  to  the  soft  palate  nor  to  the  pillars  of  the 
pharynx. 

Frequently  the  glands  at  the  angle  of  the  jaw  are  enlarged  and 
these  together  with  the  inflamed  tonsils  produce  considerable  dis- 
comfort- and  pain  on  swallowing.  A  routine  examination  of  the 
throat  in  all  cases  will  often  disclose  a  tonsillitis  which  has  produced  no 
subjective  symptoms. 

Course  and  Prognosis. — The  inflammatory  condition  is  active  for 
at  least  three  or  four  days  even  under  treatment,  but  because  of  the 
constitutional  symptoms  convalescence  may  be  slow;  ten  days  usually 
elapsing  during  this  stage.     The  prognosis  is  good  if  the  patient  is  well 


348  DISEASES  OF  CHILDREX. 

cared  for,  though  the  danger  of  endocarditis  and  the  possibility  of  peri- 
tonsillar abscess  must  not  be  forgotten. 

Differential  Diagnosis. — At  the  onset,  tonsillitis  may  be  confounded 
with  malaria,  pneumonia,  scarlet  fever,  or  influenza.  A  careful  his- 
tory and  blood  examination  will  usually  eliminate  the  first;  a  careful 
physical  examination  and  absence  of  disturbed  pulse-respiration  ratio 
would  differentiate  it  from  pneumonia,  while  further  observation  for 
twenty-four  hours  will  render  the  diagnosis  more  certain  on  account 
of  the  more  characteristic  appearance  of  the  tonsils.  From  diphtheria, 
the  absence  of  Klebs-Loeffler  bacilli,  the  sudden  onset  and  initial  chill, 
the  position  and  character  of  the  local  lesion,  the  high  temperature 
and  the  absence  of  a  history  of  exposure  to  diphtheritic  infection  point 
strongly  to  the  diagnosis  of  follicular  tonsillitis.     (See  Plate  XI.) 

In  ulceromembranous  tonsillitis,  the  constitutional  symptoms 
are  much  milder;  the  pain  in  the  throat  more  severe,  and  enlargement 
of  lymph-glands  more  marked.  The  local  lesion  is  usually  one-sided, 
the  affected  tonsil  being  covered  with  a  dirty  yellowish  exudate 
closely  resembling  the  membrane  of  diphtheria. 

Treatment. — Rest  in  bed  is  imperative  on  account  of  the  great 

danger  of  endocarditis.     Depletion  by  calomel  gr.  y^  every  half-hour 

for  ten  doses  will  reduce  the  intoxication.     Hot  fomentations  or  cold 

compresses  to  the  throat  will  give  relief  from  pain.     Alcohol  sponge 

baths  when  the  temperature  is  high  will  add  materially  to  the  comfort 

of  the  patient.     During   the   first  twelve  to  twenty-four  hours  the 

following  may  be  given  to  a  child  two  years  old. 

I^     Phenacetini   gr-  i 

Salol   gr.  j 

Oleosacchari  anisi,  q.s. 

M.     Ft.  pulv No.  j 

Misce  et  signa. — One  every  three  hour.s. 

For  young  children  who  have  not  learned  to  gargle,  a  very  eflSi- 

cient  local  application  to  be  used  on  a  swab  every  two  or  three  hours 

is  the  following: 

I^     Tincturse  iodini  HR  iv 

Argyrol    gtt.  iij 

Aquae q.s.  ad.  5ss 

Misce  et  signa. — Swab  on  tonsils  every  two  to  three  hours. 

Older  children  may  gargle  with  the  Liq.  antiseptic,  alkalinus  (N.  F.) 
or  any  of  the  equally  efficient  mild  antiseptic  solutions. 

Ulcero-membranous  Tonsillitis. 

(Vincent's  Angina.) 
Clinically,    this    affection    closely   resembles    a   mild  diphtheria; 
bacteriologically,    the   findings   show   the   presence   of  an  elongated 


DISEASES    OF   THE   UPPER    RESPIRATORY   TRACT.  349 

fusiform  bacillus  and  long  wavy  spirilli.  The  general  symptoms  are 
mild  or  absent  except  for  the  pain  in  the  throat  which  is  severe. 

The  lesion  is  a  superficial  ulcer  on  the  tonsil  the  size  of  a  dime, 
usually  unilateral  in  location,  of  a  dirty  yellow  color,  and  exhibiting 
no  great  tendency  to  spread.  The  ulceration  is  deep,  and  upon 
attempt  to  pull  off  the  membrane  the  underlying  surface  bleeds 
slightly.  The  cervical  glands  are  enlarged  and  the  muscles  -along  the 
side  of  the  neck  are  stiff  and  tender.  The  pulse  and  temperature  are 
moderately  increased,  the  latter  closely  resembling  the  temperature 
in  diphtheria. 

As  a  rule,  the  breath  is  foul  and  there  is  much  drooling.  Hot 
antiseptic  gargles  and  mildly  astringent  applications  (see  p.  348) 
locally  combined  with  hot  or  cold  external  applications  are  very 
efficient  measures  of  relief. 

The  disease  runs  much  the  same  course  as  a  follicular  tonsillitis. 
A  smear  and  culture  should  be  made  in  all  suspicious  cases  for  purposes 
of  differentiation. 


Chronic  Tonsillar  Hypertrophy. 

« 

A  condition  of  chronic  enlargement  of  the  tonsils  is  seen  in  many 
children  giving  a  history  of  repeated  attacks  of  tonsillitis,  or  as  a 
result  of  the  infectious  diseases.  Adenoid  vegetations  and  hyper- 
trophied  tonsils  are  associated  in  many  cases. 

Symptomatology. — There  is  impaired  phonation  and  the  train  of 
symptoms  which  are  associated  with  adenoids,  the  distress  being 
especially  produced  at  night  during  sleep.  Restlessness  and  snoring 
are  more  marked. 

Treatment. — Chronic  enlargements  should  be  removed.  For 
children  the  guillotine  is  preferred,  a  size  suitable  for  the  patient 
being  selected. 

Cocain  as  an  anesthetic  should  not  be  used.  If  adenoids  are 
present  remove  the  tonsils  first.  In  unruly  children  an  anesthetic 
is  necessary,  and  the  child  should  be  prepared  as  for  the  adenoid 
operation. 

The  head  may  be  slightly  raised  and  the  assistant  should  gently 
press  the  tonsils  from  the  outside,  toward  the  middle  line.  The 
results  obtained  do  not  seem  to  warrant  complete  excision  with  special 
instruments  as  has  been  advocated  by  some  throat  specialists,  but 
complete  enucleation  with  the  finger  is  often  desirable  and  produces 
less  traumatism. 


350 


DISEASES  OF  CHILDREN. 


Adenoids. 

{Hypertrophy  of  the  Pharyngeal  Tonsil.) 

This  term  is  applied  to  a  hypertrophy  of  the  lymphoid  tissue 
normally  found  in  the  pharyngeal  vault. 

Etiology. — Adenoids  are  found  at  all  ages  and  are  far  from 
infrequent  in  infants.  Children  who  have  lived  in  a  poor  hygienic 
environment  or  whose  parents  have  chronic  diseases  seem  to  inherit  a 
tendency  to  adenoids.  They  are  usually  associated  with  enlargement 
of  the  faucial  tonsils.  Rickets  and  the  condition  known  as  the 
lymphatic  diathesis  predispose  to  adenoid  vegetations.  Kerley 
believes  that  the  pernicious  use  of  the  so-called  comforter  with"  the 
constant  sucking  is  directly  productive  of  adenoids. 


Fig    102. — Typical  adenoid  face. 


Symptomatology  in  Infants. — The  symptoms  differ  considerably 
in  infants,  and  therefore  will  be  described  separately.  The  babe  may 
be  brought  because  it  cannot  suckle  without  frequently  stopping  to 
breathe  through  its  mouth.  Sleep  is  broken  and  the  infant  cries  and 
almost  chokes  when  it  drops  into  a  deep  sleep.  A  persistent  rhinitis  is 
commonly  observed,  and  sniffling  may  be  the  most  prominent  symp- 
tom.    The  expression  is  not  changed  as  in  older  children. 

In  Children. — In  early  cases  the  child  is  brought  for  examination 
because  of  frequent  "colds  in  the  head"  associated  with  troubled  sleep 


DISEASES  OF  THE  UPPER  RESPIRATORY  TRACT.        351 

and  snoring.  In  more  aggravated  conditions,  mouth-breathing, 
snoring  at  night  with  tossing,  restless  sleep,  and  occasional  night 
terrors  should  lead  to  a  careful  nasopharyngeal  examination.  In 
typical  cases,  the  vacant  expression,  fish-like  face,  and  open  mouth, 
often  with  a  high  arched  palate,  are  readily  noted.  The  face  in  these 
mouth-breathers  has  been  visibly  deformed  (Fig.  102),  and  the  following 
characteristics  make  the  diagnosis  simple:  partly  pursed  mouth,  pro- 
truding lower  jaw;  narrowed  long  face;  V-shaped  palate;  .enlarged 
tonsils;  narrow  alae  nasi;  dull  eyes;  pale  mucous  membranes;  narrowed 
chest,  sometimes  otitis  and  evidences  of  general  malnutrition.  These 
children  have  a  nasal  twang  to  the  voice  and  are  poor  scholars.  They 
tire  easily,  do  not  eat  well,  and  may  suffer  from  incontinence  of  urine. 
There  may  be  partial  deafness  from  obstruction  of  the  Eustachian 
tube.  If  a  granular  pharyngitis  with  plugs  of  mucus  hanging  from 
the  posterior  nares  is  observed,  adenoids  are  usually  present.  A 
useful  test  generally  indicating  nasal  obstruction  due  to  adenoids  is  to 
request  the  child  to  repeat  the  words  "clapham  common"  which  he 
cannot  enunciate  without  a  nasal  twang. 

Examination. — In  infants  it  is  a  difficult  procedure,  but  may  be 
occasionally  accomplished  with  care  and  patience;  the  little  finger  must 
be  used  for  exploration  as  the  space  is  so  small.  In  older  children 
the  finger  properly  protected  should  be  passed  into  the  nasopharyngeal 
space  and  the  amount  and  character  of  the  adenoid  tissue  appreciated. 
Soft  pendulous  masses  or  firm  growths  may  be  felt  and,  if  the  vault  is 
found  to  be  occluded  with  hypertrophied  tissue,  operative  interference 
should  be  resorted  to.  Occasionally  it  is  necessary  to  give  a  whiff  of 
chloroform  before  the  examination  can  be  made,  or  this  can  be  deferred 
until  ready  to  operate. 

Treatment  in  Infants. — If  the  symptoms  of  obstruction  are  such 
as  to  interfere  with  the  infant's  nutrition,  the  adenoids  should  be 
carefully  and  completely  removed  by  an  expert.  Palliative  measures 
are  ofttimes  successful  in  less  aggravated  cases,  and  we  have  found 
the  instillation  of  a  mixture  such  as  the  following  to  be  of  benefit : 

I^    Camphorae gr.  j 

Menthol      gr.  ^ 

Resorcini gr.  ij 

Benzoinol 5j 

Misce  et  signa. — Five  drops  every  three  hours  into  the  nose  with  a 
medicine  dropper. 


or 


I^     Adrenalini  inhalantis    3ss 

Liquidi  albolini q.  s.  ad  5ss 

Misce  et  signa. — A  few  drops  in  nose,  night  and  morning. 


352  DISEASES  OF  CHILDREN. 

In  Older  Children. — Palliative  measures  here  are  useless.  The 
operation  should  be  performed  under  a  general  anesthetic  if  there  are 
no  contraindications,  such  as  bronchitis,  acute  tonsillitis,  etc.  The 
adenoids,  and  if  present,  the  enlarged  tonsils  are  removed  at  the 
same  time.  The  after-treatment  is  to  break  up  the  habit  of  mouth- 
breathing  by  careful  instructions  in  proper  breathing  and  corrective 
exercise.     (See  page  79.) 

Peritonsillar  Abscess. 

(Quinsy.) 

A  retropharyngeal  abscess  is  more  common  in  infancy  than  peri- 
tonsillar abscess.  Older  children,  however,  have  abscess  formation  in 
the  peritonsillar  tissue,  accompanied  by  fever,  chilliness,  and  difficult 
swallowing.  The  mouth  is  opened  with  difficulty  and  the  tonsil  on  one 
side  is  seen  to  bulge  forward.  The  finger  elicits  fluctuation  when  the 
condition  is  at  its  height. 

Treatment. — In  the  early  stages  calomel  or  effervescent  citrate  of 
magnesia  may  be  given  for  the  bowels.  Salol  and  phenacetin,  one  and 
a  half  grains  of  each,  may  be  given  every  three  hours  for  a  five-year- 
old  child.  Cold  milk  sucked  through  a  tube  is  agreeable  and  keeps 
up  nutrition.  Incise  with  a  guarded  scalpel,  and  drain  as  soon  as  a 
diagnosis  of  an  abscess  is  made.  A  gargle  and  occasional  digital 
pressure  for  evacuation  of  the  pus  made  over  the  affected  site  serve 
to  prevent  reinfection. 

Retropharyngeal  Abscess. 

This  abscess  is  seen  not  rarely  in  infants  and  children  below  the 
age  of  two  years.  Ill-nourished  children  are  more  prone  to  it  because 
of  their  lowered  vitality,  and  infection  takes  place  from  the  organisms 
commonly  found  in  the  mouth. 

Symptomatology. — The  infant  is  usually  brought  for  examination 
because  of  difficulty  in  breathing.  In  the  early  stages  there  is  mainly 
an  inspiratory  dyspnea,  but  as  the  abscess  grows  larger  difficulty  is 
experienced  both  in  inspiration  and  expiration.  During  sleep  there 
is  a  persistent  rattling  snore  and  the  child  frequently  awakes  to 
change  its  position.  The  child  refuses  nourishment  or  takes  it 
with  great  difficulty.  The  temperature  is  irregular  and  fluctuates 
from  100°  to  103°  F.  When  the  head  is  bent  forward,  the  dyspnea  is 
increased. 


DISEASES    OF    THE    UPPER    RESPIRATORY    TRACT.  353 

Inspection  with  a  suitable  tongue  depressor  will  show  a  rounded 
reddened  mass  protruding  almost  from  the  center  or  on  one  side  of  the 
pharyngeal  wall.     The  examining  finger  detects  fluctuation. 

Treatment. — It  is  imperative  that  the  abscess  be  opened  and 
thoroughly  drained.  The  child's  head  should  be  held  well  forward 
and  then  downward  when  the  abscess  has  been  opened  to  prevent  as- 
piration of  the  pus.  Strychnin  and  whisky  are  usually  indicated  to 
combat  the  septic  absorption.  In  a  few  of  our  cases  it  has  been  neces- 
sary to  feed  the  child  by  gavage  for  a  few  days  following  the  evacuation 
of  the  pus. 

Acute  Laryngitis. 

(Spasmodic  Croup;  Spasmodic  Laryngitis;  False  Croup; 
Catarrhal  Croup.) 

Etiology. — This  is  usually  due  to  bacterial  infection  made  possible 
by  sudden  exposure  to  cold  or  wet.  It  is  most  commonly  met  with 
from  the  second  to  the  fifth  year  of  life  and  is  apt  to  recur.  Laryngitis 
occasionally  antecedes  the  eruption  in  measles.  Children  with  naso- 
pharyngeal obstructions  are  predisposed  to  the  affection. 

Symptomatology. — The  attacks  usually  come  on  in  the  evening 
or  at  night.  The  child  has  appeared  to  be  quite  well  during  the  day, 
and  no  symptoms  have  been  observed  except  a  slight  rhinitis.  With- 
out warning  a  croupy  harsh  and  brassy  cough  develops,  accompanied 
by  loud  croupy  breathing,  heard  with  inspiration,  expiration  being 
quite  noiseless.  The  patient  is  alarmed  and  the  sleep  is  restless. 
The  cough  thoroughly  alarms  the  mother  and  her  fright  is  communi- 
cated to  the  child.  In  severe  attacks  the  patient  must  sit  up  in  bed  to 
breathe;  the  suprasternal  notch  and  diaphragmatic  groove  are  re- 
tracted. After  the  attacks  the  child  is  exhausted  and  wet  with  per- 
spiration. There  may  or  may  not  be  any  temperature.  The  attacks 
even  if  uninfluenced  by  treatment,  subside  toward  the  morning 
hours,  the  harsh  breathing  ceases,  and  the  child  quietly  rests.  On 
the  succeeding  day  the  patient  is  ready  to  play  and  the  cough  while 
present  is  not  annoying.  For  several  nights  there  will  be  a  repetition 
of  the  dyspnea  and  croupy  cough. 

Diagnosis. — Laryngeal  diphtheria  must  be  excluded.  In  diph- 
theria the  breathing  slowly  becomes  worse  with  no  remissions.  The 
constitutional  symptoms  are  more  marked  and  the  inspiratory 
stridor  may  be  present  without  the  croupy  cough.  Seek  safety  in  a 
culture,  and  if  the  weight  of  evidence  leans  toward  diphtheria  give 
antitoxin. 
23 


354  DISEASES  OF  CHILDREN. 

Differential  Diagnosis. 

Acute  Laryngitis.  Diphtheritic  Laryngitis. 

Sudden  onset.  More  gradual  invasion. 

Dyspnea  intense  from  start  but     Dyspnea  slowly  but  progressively 

evanescent.  worse. 

Cough      resonant      and     brassy     Cough  muffled  and  suppressed. 

(barking). 
Voice,  usually  normal.  Voice  muffled  and  almost  lost. 

Inspiratory  and  expiratory  stridor. 
Inspiratory  stridor.  Inspiratory  more  marked. 

Albumin  rarely  in  urine.  Albumin  commonly  found. 

No  membrane  seen.  Membrane  may  be  seen  in  pharynx 

and  tonsils  or  coughed  up. 

For  differential  diagnosis,  from  Laryngismus  Stridulus,  see  p.  356. 

Retropharyngeal  abscess  will  be  differentiated  by  the  increase 
in  dyspnea  when  the  head  is  dropped  forward  and  by  directly  palpat- 
ing a  fluctuating  mass. 

Prognosis. — Distinctly  favorable,  never  fatal,  but  recurrences 
are  common. 

Treatment. — Place  the  child  in  a  warm,  moist  room.  In  mild 
cases  an  emetic  dose  of  the  wine  of  ipecac,  half  a  dram  every 
half-hour  until  vomiting  ensues,  may  be  sufficient  to  give  relief.  A 
warm  mustard  bath  aids  the  result.  An  enema  should  be  ordered  if 
the  bowels  have  not  recently  moved.  In  severer  cases  a  croup  tent 
(see  page  103)  should  be  made  over  the  crib  and  a  croup  kettle 
started  in  which  has  been  placed  a  dram  or  two  of  the  compound 
tincture  of  benzoin.  Emesis  should  be  brought  about  as  rapidly  as 
possible.  Antipyrin  gr.  3  for  a  three-year-old  child  acts  as  an  anti- 
spasmodic. If  there  is  cyanosis  and  serious  obstruction  intubation 
may  be  necessary,  however  a  smear  and  culture  should  be  made  in 
these  cases  to  exclude  diphtheria. 

The  succeeding  day  should  be  spent  quietly,  a  light  diet  given  and 
the  bowels  kept  open.  If  there  are  adenoids  present,  these  should 
be  removed  at  a  later  date. 

,;  ,,  Edema  of  the  Glottis. 

(Submucous  laryngitis.) 
Definition. — This  is  an  infiltration  of  serum  into  the  submucous 
layer  of  the  glottis  and  the  neighboring  aryepiglottic  folds. 

Etiology. — Serous    infiltration    may    result    from    the    irritative 


DISEASES  OF  THE  UPPER  RESPIRATORY  TRACT. 


355 


action  of  corrosive  drugs  accidently  swallowed,  from  foreign  bodies,  or 
it  may  occur  during  the  course  of  nephritis,  syphilis,  the  infectious 
diseases,  streptococcic  inflammation  of  the  larynx  or  its  neighboring 
structures  by  extension.  It  occasionally  occurs  in  severe  cardiac 
affections  and  with  extensive  edema  of  the  lungs.  Tumors,  such  as 
papillomata,  have  produced  the  condition.  The  angioneurotic 
type  of  edema  of  the  glottis  is  extremely  rare. 


Fig.  103.— Croup  tent. 


Symptomatology. — The  striking  symptom  is  the  inspiratory  dysp- 
nea which  results.  There  is  usually  some  stridor  and  a  muffled  voice. 
Pain  and  dysphagia  are  present  when  the  edema  is  the  result  of  a 
local  inflammation  resulting  from  trauma,  hot  steam,  acids,  etc. 

Inspection  shows  an  enlarged  mucous  membrane,  swollen  epiglot- 
tis, and  narrowed  rinna  glottidis.  The  folds  of  mucous  membrane  may 
overhang  the  glottis.  The  edema  may  be  felt  by  the  finger  or  seen  by 
the  laryngeal  mirror. 

Course  and  Prognosis. — The  course  and  prognosis  are  directly 
proportionate  to  the  severity  of  the   underlying  disease  or  to  the 


356  DISEASES  OF  CHILDREN. 

amount  of  trauma  that  has  been  caused.  UnreUeved  cases  of  edema 
of  the  glottis  often  terminate  fatally.  The  milder  types  due  to  the 
infectious  diseases  and  kidney  disease  improve  with  the  amelioration 
of  the  primary  cause. 

Treatment. — In  mild  cases  attention  should  be  directed  principally 
to  the  underlying  disease.  Diaphoretics  and  diuretics  are  distinctly 
helpful.  Dover's  powders  will  allay  pain  and  restlessness  until  more 
heroic  measures  are  taken.  Scarification  is  occasionally  successful 
in  giving  relief  when  performed  by  a  specialist.  Tracheotomy  is  to 
be  preferred  to  intubation  in  desperate  cases  when  suffocation  is 
imminent. 


Laryngismus  Stridulus. 

Laryngismus  stridulus  is  a  neurotic  disease  of  infancy,  charac- 
terized by  spasmodic  attacks  affecting  the  glottis  and  the  neighboring 
laryngeal  muscles. 

Etiology. — Rachitic  infants  and  those  with  adenoids  are  especially 
predisposed.  Exposure  to  irritating  gases  or  vapors,  or  badly  ven- 
tilated apartments  may  bring  on  an  attack. 

Symptomatology. — This  varies  with  the  severity  of  the  disease 
and  with  the  particular  spasm.  In  some  cases  the  spasm  is  but 
momentary  ending  with  an  inspiratory  crow;  again  it  may  recur  every 
few  moments  with  but  slight  inconvenience  to  the  patient.  In  severe 
attacks  the  crowing  inspiration  is  distinctly  audible,  the  infant 
becomes  spastic,  and  the  efforts  to  breathe  are  marked.  Lividity 
of  the  face  ard  a  gasping  expression  are  observed.  Carpopedal 
spasm  and  in  some  instances  convulsions  follow  severe  attacks.  In 
the  intervals  the  breathing  may  be  quite  free  and  unobstructed,  with 
no  constitutional  symptoms.  Fatal  cases  are  rare,  but  have  been 
reported. 

Laryngismus  Stridulus.  Spasmodic  Croup. 

(Acute  Laryngitis.) 
Ill-nourished   infants    under    two     Commonly  from  two  to  five  years. 

years. 
No  pyrexia.  Some  pyrexia, 

No  cough  or  rhinitis.  Brassy  cough  and  coryza. 

Attacks    momentary    and    recur     Attacks   usually    at  night,    last 
often.  longer  and  have  longer  periods 

of  remission. 


DISEASES    OF   THE    UPPER    RESPIRATORY   TRACT.  357 

Treatment. — In  the  severe  cases,  emesis  with  wine  of  ipecac  in  half- 
dram  doses  every  half-hour  until  vomiting  ensues  may  be  employed, 
with  cold  sponging  of  the  face  and  chest.  A  cleansing  enema  in  a 
badly-fed  rickety  infant  is  often  effectual.  The  underlying  cause 
must  be  removed  or  combated  in  the  interval.  Adenoids  should  be 
removed,  and  the  infant  placed  on  a  properly  proportioned  diet.  This 
alone  is  curative  in  certain  babies  fed  on  the  proprietary  foods.  A 
quiet  atmosphere  and  a  well-regulated  dietary  will  cure  the  majority 
of  cases. 

Congenital  Laryngeal  Stridor. 

{Congenital  Infantile  Stridor.     Thymic  Asthma.) 

This  congenital  condition  is  rare  and  is  often  confused  with 
laryngismus  stridulus. 

Etiology. — There  is  still  confusion  as  to  the  causation.  One 
theory  is  that  it  is  due  to  a  poorly  coordinated  action  of  the  respira- 
tory muscles  involved  in  the  act  of  breathing.  The  epiglottis  is 
deformed  as  a  result,  and  inspiration  then  produces  the  peculiar  crow- 
ing respiration  of  the  affection.     (Thomson.) 

Sometimes  a  narrowed,  infolded  and  thinned-out  epiglottis  is 
found  which  can  be  observed  by  laryngoscopic  examination  to  cause 
the  peculiar  sounds.  Variot  claims  that  the  condition  is  found  in  the 
lymphatic  diathesis  and  that  it  is  caused  by  an  enlarged  thymus, 
his  observations  being  confirmed  by  X-ray  examinations.  Others 
believe  it  to  be  a  pure  neurosis  dependent  upon  an  underlying  nutri- 
tional defect. 

Symptomatology. — From  birth  there  is  heard  mainly  on  inspira- 
tion a  high-pitched  rasping  croak;  with  expiration  this  is  heard  only 
with  difficulty  or  not  at  all.  Crying  or  excitement  of  any  kind 
increases  the  stridor  and  even  retraction  of  the  thoracic  spaces.  On  the 
other  hand,  it  is  rarely  audible  during  quiet  sleep.  The  voice  is  not 
affected  even  in  crying.     There  is  no  cyanosis  produced  by  obstruction. 

Diagnosis. — This  is  founded  upon  the  inspiratory  stridor  present 
since  birth  in  a  child  otherwise  unaffected  as  to  development  and  who 
is  not  made  sick  or  uncomfortable  by  the  condition.  Laryngoscopic 
examination  or  a  direct  examination  of  the  epiglottis  can  be  quite 
often  made  in  infants  with  a  correctly-shaped  tongue  depressor. 
Laryngismus  stridulus  (p.  356)  is  found  mainly  in  rachitic  children, 
is  rare  before  the  dentition  period,  and  is  often  associated  with 
tetany.  New  growths  of  the  larynx  should  be  ruled  out  by  careful 
examination. 


358  DISEASES  OF  CHILDREN. 

Course  and  Prognosis. — Up  to  the  end  of  the  first  year  the  condi- 
tion is  at  its  worst;  then  amelioration  begins  and  at  the  second  year 
it  quite  disappears.  The  physical  condition  is  not  affected,  but  super- 
added diseases  of  the  respiratory  tract  are  apt  to  have  a  fatal  issue. 

Treatment. — The  condition  does  not  lend  itself  to  any  form  of 
treatment,  but  the  intubation  tube  and  instruments  for  tracheotomy 
should  be  on  hand  if  any  respiratory  disease  complicates  it. 

New  Growths  of  the  Larynx. 

Papillomata. — Although  by  no  means  common,  they  are  not 
rare.  They  may  be  congenital  or  attributed  to  the  specific  fevers. 
Distinct  continued  hoarseness  is  the  prominent  symptom.  As  the 
growth  later  on  causes  obstructive  symptoms,  dyspnea  or  suffocative 
attacks  follow.  The  diagnosis  may  be  made  or  confirmed  by  the  use 
of  the  Killian's  tube  (bronchoscopy).  Intubation  may  be  practised 
for  immediate  relief  and  then  an  endolaryngeal  operation  may  be  per- 
formed. If  this  is  not  feasible,  tracheotomy  must  be  resorted  to. 
Fibromata  are  rarely  seen  in  early  life. 


CHAPTER  XXVI. 
DISEASES  OF  THE  LUNGS  AND  PLEURA. 

Acute  Bronchitis. 

This  is  an  acute  inflammation  of  the  mucous  membrane  of  the 
large  and  medium-sized  bronchi.     It  is  a  frequent  disease  in  early  life. 

Etiology. — Bronchitis  results  as  an  infection  following  lowered 
resistance  from  exposure,  malnutrition,  rickets,  enlarged  tonsils, 
adenoids,  valvular  disturbances,  or  following  the  infectious  diseases. 
Irritating  gases  or  dust  particles  may  also  cause  a  form  of  bronchitis. 
The  bacteria  found  in  the  secretions  are  many  and  varied  and  of  the 
types  commonly  found  in  the  bronchial  tract. 

Symptomatology. — The  symptoms  usually  begin  with  a  coryza, 
or  follow  an  obstinate  rhinitis  or  tracheitis.  There  is  a  hard,  dry  cough 
which  soon  becomes  loose  as  more  mucus  is  produced.  The  pulse  and 
temperature  are  slightly  elevated,  rarely  over  101°  F.  during  the  day, 
but  may  be  a  degree  or  two  higher  in  the  evening,  while  the  respirations 
are  always  higher  than  normal.  The  child,  as  a  rule,  does  not  com- 
plain and  may  be  quite  willing  to  be  about;  infants,  however,  are  often 
restless  and  irritable  and  vomiting  may  result  from  an  attack  of 
coughing.  The  stools  are  rarely  normal,  either  constipation  or  loose 
stools  being  observed.  It  must  be  recollected  that  the  sputum  is 
swallowed  by  infants  and  children  up  to  five  years  of  age.  The 
disease  tends  to  recovery  in  from  five  days  to  a  week.  Severer  forms 
are  seen  which  are  due  to  involvement  of  the  smaller  bronchi  (formerly 
termed  capillary  bronchitis)  in  which  the  symptoms  are  more  pro- 
nounced and  there  is  some  dyspnea.  The  pulse  and  respiratory 
ratio  may  be  somewhat  disturbed  and  a  pneumonic  process  result 
from  infection  of  the  alveoli. 

Physical  Signs. 

Inspection. — Breathing  is  quickened,  and  there  may  be  recession 
of  the  softer  parts  of  the  chest  wall   especially  in  rickety  children. 

Percussion. — No  changes  from  the  normal. 

Auscultation. — Exaggerated  puerile  breathing  and  rales  of  varied 
character,  according  to  the  location  of  the  inflammation,  are  found. 

359 


360  DISEASES  OF  CHILDREN. 

Large,  coarse  rales  (ronchi)  over  the  larger  tubes  and  moist  rales  with 
finer  rales  over  the  smaller  bronchi  may  be  noted. 

Tactile  fremitus  is  often  distinct  in  infants  when  the  secretions 
are  viscid. 

Diagnosis. — The  differential  diagnosis  is  to  be  made  from  broncho- 
pneumonia, in  which  the  temperature  is  higher  with  a  disturbed  pulse 
and  respiration  ratio,  by  the  grunting  respiration  and  dyspnea. 
The  physical  examination  does  not  elicit  dullness  and  subcrepitant 
r^les  as  in  pneumonia.  In  pulmonary  collapse  there  is  dullness  on 
percussion  and  absence  of  respiratory  murmur  and  subnormal 
temperature. 

Prognosis. — This  is  usually  good  except  in  cases  of  rickets  and 
after  the  infectious  diseases,  when  pneumonia  is  likely  to  follow. 
Young  infants,  however,  may  die  from  a  simple  bronchitis  when  the 
tubes  become  obstructed  with  mucus  followed  by  cyanosis. 

Treatment. — Rest  for  the  patient  and  fresh  air  are  necessary 
requirements.  A  change  to  a  different  climate  will  often  alone  effect 
a  cure.  The  bowels  should  be  opened  with  a  grain  of  calomel  in  divided 
doses  or  one  or  two  drams  of  castor  oil.  The  diet  is  to  be  restricted 
and  water  freely  given.  If  the  temperature  is  unduly  high  and  is 
causing  discomfort,  an  alcohol  rub  is  indicated.  The  use  of  hot 
poultices  and  jackets  are  mentioned  only  to  be  condemned,  and  the 
same  may  be  said  of  the  so-called  syrupy  cough  mixtures.  If  the 
secretions  are  persistently  dry  and  the  cough  harassing,  the  Liq. 
ammonia  anisatis  in  3  to  5  drop  doses  in  water  to  a  child  of  five  years 
or  in  the  following  mixture  will  prove  useful,  and  will  not  disturb 
the  digestive  apparatus. 

I^     Liquor  ammonii  anisatis 5j 

Potassii  iodidi    gr.  iv 

Glycerini     5ss 

Aquae    qs.  ad.  5ij 

Misce  et  signa. —  5j  every  three  hours. 

or  the  aromatic  spirits  of  ammonia  in  five  to  ten  drop  doses,  diluted, 
is  also  effective. 

Do  not  give  muriate  of  ammonia  to  children.  If  at  night  a  sed- 
ative is  necessary  to  allow  the  child  to  sleep,  appropriate  doses  of  any 
of  the  following  drugs  may  be  given: 

Codein,  Tincture  opii  camphorata,  Antipyrin,  or  Sodium  bromid. 

The  room  is  to  be  kept  well  ventilated  and  the  temperature  not 
above  70°  F.  An  enforced  rest  in  bed  with  no  further  treatment  than 
a  free  catharsis  is  often  alone  curative.     If  the  child  has  adenoids 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  361 

and  enlarged  tonsils,  these  should  be  removed  at  a  later  date  to  prevent 
subsequent  attacks. 

Chronic  Bronchitis. 

Etiology. — This  may  result  from  repeated  attacks  of  the  acute 
form.  Children  suffering  from  disease  of  the  heart,  kidneys,  or 
liver  are  prone  to  pulmonary  congestion,  and  thus  acquire  a  chronic 
bronchitis. 

Rachitic  children,  those  with  a  tendency  to  lymphatism  and 
adenoids,  and  those  with  a  tuberculous  diathesis  are  often  afflicted 
with  chronic  bronchitis. 

Symptomatology. — Fever  is  rarely  observed  and  the  child  is  not 
incapacitated  from  its  play.  The  cough  is  often  mistaken  for  per- 
tussis and  is  worse  at  bedtime  and  upon  arising.  Older  children 
expectorate  an  abundant  frothy  mucoid  secretion,  while  younger 
children  may  swallow  or  vomit  it. 

The  physical  signs  are  more  marked  when  there  is  an  accumulation 
of  mucus  and  almost  disappear  in  the  quiescent  stage.  During  the 
warmer  months  the  cough  may  entirely  disappear. 

Diagnosis. — From  pertussis  the  differential  diagnosis  is  made 
by  the  course  and  the  paroxysmal  attacks  followed  by  vomiting. 
Tuberculosis  may  be  differentiated  by  the  recent  tuberculin  tests, 
the  absence  of  fever,  and  the  physical  signs. 

Prognosis. — The  prognosis  bears  a  distinct  relation  to  the  etiologi- 
cal factor.  If  this  can  be  remedied,  as  adenoids  for  example,  much 
improvement  may  be  expected.  If  there  is  glandular  enlargement 
present  or  a  tuberculous  tendency,  the  outcome  is  not  as  hopeful. 

Treatment. — First  remove  if  possible  the  underlying  cause. 
Climatic  treatment  is  often  productive  of  good  results.  Tonics  such 
as  the  syrup  of  the  iodid  of  iron  and  cod-liver  oil  are  serviceable. 
Carbonate  of  guaiacol  in  3  to  5  grain  doses  in  sugar  of  milk  is  beneficial 
for  the  cough. 

Pulmonary  Collapse. 

Collapse  of  small  areas  of  the  lung  occurs  frequently  and  quite 
easily  in  infancy.  The  condition  may  occur  in  cases  of  bronchitis 
and  in  obstruction  or  stenosis  of  the  upper  respiratory  tract  or  the 
bronchi. 

Children  with  rickets  are  particularly  predisposed,  as  the  condi- 
tion is  dependent  upon  the  yielding  nature  of  the  thoracic  walls  in 
early  life. 


362  DISEASES  OF  CHILDREN. 

Symptomatology. — Superficial  areas  cannot  be  detected  by  phys- 
ical examination,  nor  do  they  produce  any  noticeable  symptoms. 
Larger  areas  give  rise  to  very  marked  and  sudden  symptoms.  The 
child's  condition  suddenly  changes  to  one  of  cyanosis;  his  restlessness 
is  dependent  upon  the  inability  to  get  air;  the  breathing  is  extremely 
shallow  and  gasping;  the  supraclavicular  spaces  show  marked  recession 
with  each  effort  of  breathing.  A  fatal  issue  may  be  preceded  by 
convulsions. 

Physical  Examination. — Dullness,  or  dullness  to  flatness,  over  the 
collapsed  area  is  noted.  On  auscultation,  the  breath  sounds  are  en- 
tirely absent.  The  crying  voice  is  diminished.  Areas  of  compensatory 
emphysema  are  present,  usually  in  the  upper  portion  of  the  chest. 
These  signs,  with  the  history  of  sudden  onset,  in  a  child  suffering  from 
a  previous  pulmonary  condition  should  cause  no  confusion  in  the 
diagnosis. 

Treatment. — A  full  hot  mustard  bath  followed  by  artificial  res- 
piration may  be  employed  in  desperate  cases.  Holding  the  infant  by 
the  heels  may  succeed  in  producing  an  effort  at  deep  inspiration,  and 
will  dislodge  any  considerable  amount  of  mucus  that  may  have  acted 
as  the  cause  of  the  collapse.  The  production  of  emesis  by  the  intro- 
duction of  the  finger  in  the  throat  should  be  tried.  If  the  secretions 
are  still  found  to  be  considerable  in  amount  after  amelioration  of  the  col- 
lapse, a  hypodermatic  injection  of  atropin  sulphate  -g^-^  gr.  will  be 
efficacious.     A  trained  attendant  should  be  placed  in  charge. 

Emphysema. 

Emphysema  in  some  degree  occurs  very  frequently  in  infants 
and  children  suffering  from  bronchial  affection. 

Acute  emphysema  occurs  most  frequently  in  bronchitis,  broncho- 
pneumonia, pertussis,  stenosis  of  the  larynx,  and  pulmonary  collapse. 
It  is  produced  by  overdistention  of  the  weak  elastic  tissue  of  the 
alveoli  when  the  glottis  is  closed  in  violent  efforts  of  coughing. 

Children  suffering  from  chronic  bronchitis  frequently  have  an 
accompanying  emphysematous  condition  which  does  not  recede  until 
some  time  after  all  evidences  of  the  bronchitis  have  disappeared. 

This  condition  of  chronic  emphysema  is  not  often  seen  in  child- 
hood. The  diagnosis  is  based  upon  the  abnormally  full  and  rounded 
chest,  the  hyperresonant  note  on  percussion,  the  diminution  of  the 
area  of  relative  cardiac  dullness  and  the  sonorous  and  sibilant  rales 
heard  all  over  the  chest  with  unduly  prolonged  expiration. 

The  prognosis  and  treatment  are  mainly  those  relating  to  the 
underlying  conditions. 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  363 

Bronchial  Asthma. 

This  is  a  disease  not  common  to  early  life  and  is  due  to  a  spasmodic 
contraction  of  the  bronchial  tubes  as  a  result  of  some  form  of  patho- 
logical stimulation  of  the  bronchial  muscles. 

Etiology. — Salter  records  225  cases,  among  which  11  began  the 
first  year  of  life,  and  60  as  occurring  from  the  first  to  the  tenth  year  of 
life. 

Bronchitis  is,  in  the  majority  of  instances,  the  predisposing 
disease.  Nasal  obstructions,  especially  adenoids,  are  important 
etiological  factors.  They  were  present  in  47  per  cent,  of  La  Fetra's 
cases. 

Symptomatology. — The  attack  may  begin  with  a  fairly  pronounced 
bronchitis  which  lasts  for  several  days;  then  there  may  be  suddenly 
superadded  dyspnea  with  its  accompanying  rapid  respiration,  anxious 
expression,  and  rarely  cyanosis. 

Inspection  of  the  chest  during  the  paroxysm  shows  retraction  in 
the  suprasternal  and  supraclavicular  spaces,  and  the  activity  of  the 
accessory  muscles  of  inspiration. 

Auscultation. — Sibilant  and  sonorous  rales  are  heard  both  during 
inspiration  and  expiration  all  over  the  chest. 

Percussion. — A  hyperresonant  note  is  elicited  during  the  height  of 
the  attack.  There  is  rarely  any  temperature  unless  the  attack  has 
closely  followed  an  acute  bronchitis.     It  rarely  rises  above  102°  F. 

Blood  examinations  may  be  of  assistance  from  the  standpoint  of 
differential  diagnosis.  Polymorphonuclear  eosinophiles  are  increased 
in  number,  while  in  prolonged  subacute  cases  a  relatively  lower 
eosinophilia  is  found. 

Treatment. — Adenoids,  enlarged  tonsils,  and  other  obstructions  to 
proper  breathing  must  be  removed.  Attacks  of  bronchitis  are  to  be 
guarded  against.  A  careful  process  of  hardening  by  hydrotherapy 
or  a  change  of  environment  may  be  necessary  to  prevent  repeated 
attacks.  Careful  oversight  of  the  diet  must  be  observed  and  indiges- 
tion avoided. 

The  indication  for  the  treatment  of  the  acute  attack  is  the  relief 
of  the  bronchial  spasm.  For  this  purpose  a  combination  of  the  iodids 
and  bromids  is  of  distinct  service.  The  bowels  should  be  emptied  with 
a  soapsuds  enema,  and  if  there  is  any  history  of  indiscretion  in  diet, 
an  emetic  dose  of  the  wine  of  the  syrup  of  ipecac  given. 

Nitroglycerin  yi^  to  y|^  of  a  grain,  or  atropin  -^^  of  a  grain 
for  a  two-year-old  child  may  be  necessary  for  relief  in  severe  cases. 
The  syrup  of  the  iodid  of  iron  is  valuable  following  the  attack. 


364  DISEASES  OF  CHILDREN. 

Acute  Bronchopneumonia. 

(Lobular  Pneumonia,  Catarrhal  Pneumonia,  Capillary  Bronchitis.) 

This  is  perhaps  the  most  common  disease  of  infancy  and  is  very 
often  a  secondary  manifestation. 

Bronchopneumonia  occurs  most  frequently  in  early  life,  and  is 
secondary  to  an  involvement  of  the  bronchial  tubes. 

It  is  most  often  met  with  during  the  first  two  years  of  life,  and  is 
rarely  seen  after  the  sixth  year.  Bronchitis,  the  infectious  diseases, 
especially  measles,  pertussis,  influenza,  diphtheria,  and  scarlet  fever 
are  the  predisposing  causes.  Children  with  nckets,  marasmus, 
syphilis,  nephritis,  and  gastroenteritis,  especially  if  they  are  in  bad 
hygienic  circumstances,  have  their  resistance  lowered,  and  are  thus 
predisposed.  Infants  in  asylums  and  institutions  are  especially 
prone  to  the  affection.  The  pneumococcus  of  Frankel,  Friedlander's 
bacillus,  strepto-  and  staphylococci,  and  the  bacterial  flora  of  the 
nose  and  mouth  are  the  exciting  causes. 

Pathology. — The  pneumonic  areas  result  from  extension  of  the 
inflammation  through  the  bronchial  walls  and  from  the  bronchial 
walls  themselves  into  the  peribronchial  tissue.  Thus  not  only  the 
alveoli  to  which  the  bronchial  tubes  lead  are  involved,  but  also  those 
which  surround  the  tube.  The  alveoli  become  invaded  by  the 
bacteria  and  distended  with  white  blood-cells,  and  contain  some  fibrin 
and  red  blood-cells.  The  small  patches  soon  coalesce  and  become  the 
size  of  a  half-dollar  or  even  in  exceptional  instances  involve  the  greater 
part  of  one  lobe.  On  cut  section,  the  bronchioles  are  found  partly 
dilated  and  a  mucopurulent  exudate  flows  out  on  pressure.  The 
bronchial  glands  at  the  root  of  the  lung  may  be  infiltrated  and  an 
increase  in  the  interstitial  tissue  is  found  in  the  older  cases.  Pleuritis 
is  seen  with  any  considerable  area  of  pneumonia.  Accumulations  of 
fluid,  small  in  amount,  are  not  uncommon  at  autopsy.  The  same  may 
be  said  of  emphysema,  gangrene,  and  multiple  lung  abscesses. 

Symptomatology. — There  are  few  diseases  in  which  the  symptoms 
may  be  so  varied  as  in  bronchopneumonia.  The  following  descrip- 
tion will  show  how  varied  the  symptomatology  may  be,  and  what  wide 
differences  are  found  in  the  physical  signs.  The  disease  may  be 
ushered  in  with  vomiting  or  high  temperature.  On  the  other  hand, 
fever  may  be  absent  or  extremely  low  throughout  the  disease.  There 
usually  is  restlessness,  rapid  breathing,  and  a  cough  which  may  be 
severe  or  scarcely  noticeable.  If  the  disease  follows,  as  it  usually 
does,  an  attack  of  bronchitis,  all  the  symptoms  which  were  present 
are  exaggerated  while  the  breathing  becomes  labored  and  the  tem- 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  365 

preratue  increases.  The  cry  is  stifled  and  an  expiratory  grunt  which 
is  quite  characteristic  of  acute  lung  involvement  is  heard.  The  pulse 
rate  is  much  increased,  rising  to  120  or  180,  and  is  small  in  character. 
The  respirations  are  increased  to  60  or  80,  and  the  efforts  made  to  get 
enough  oxygen  are  shown  at  the  peripneumonic  groove  and  by  the 
dilated  alae  nasi.  If  a  considerable  portion  of  the  lung  is  involved, 
cyanosis  in  the  lips  or  finger-nails  is  observable.  The  child  feels 
distinctly  sick;  it  may  refuse  food,  but  usually  takes  water  eagerly. 
The  tongue  is  dry  and  coated.  The  dyspnea  increases,  and  the  cough 
may  be  harassing  and  suppressed.  The  pulse  becomes  weaker,  and 
the  hands  and  feet  are  cold.  Sleep  is  fitful  and  constantly  disturbed 
by  efforts  to  cough.  If  the  disease  progresses  and  the  temperature 
remains  persistently  high,  stupor,  delirium,  or  even  coma  may  ensue. 
The  pulse  may  become  irregular.  The  heart  action  may  give  indi- 
cations of  myocardial  changes  and  convulsions  may  precede  a  fatal 
termination.  Improvement  or  retrogression  of  the  affection  is  shown 
by  a  decreased  number  of  respirations  and  a  more  normal  pulse- 
respiration  ratio.  The  character  of  the  pulse  improves,  the  infant 
takes  some  interest  in  his  surroundings,  sleeps  more,  and  finally  takes 
nourishment  eagerly. 

Physical  Signs. — The  objective  symptoms  vary  as -greatly  as  the 
subjective  signs.  The  examiner  must  not  be  astonished  if  he  finds 
signs  not  commensurate  with  the  degree  of  prostration. 

Palpation. — Little  or  no  satisfactory  information  is  obtained. 
However,  the  apex  beat  of  the  heart  may  be  located  and  pain  on  han- 
dling appreciated. 

Inspection. — Rapid,  labored  breathing  is  noted.  The  alae  nasi 
are  dilated,  and  there  may  be  some  degree  of  cyanosis  visible.  Re- 
traction of  the  peripneumonic  groove  is  observed  in  advanced  cases. 

Auscultation. — Auscultation  with  inspection  are  of  the  greatest 
value.  A  pause  between  inspiration  and  expiration  occurs,  and  can 
be  appreciated  if  the  child  is  quiet  or  sleeping.  The  bronchitis  present 
will  be  revealed  by  coarse  moist  rMes,  often  sonorous  in  character. 
Subcrepitant  and  crepitant  rales  with  diminished  breathing  heard  at 
the  end  of  inspiration  over  a  limited  area  reveal  the  location  of  the 
pneumonic  involvement.  These  are  best  heard  when  the  infant  is 
crying  or  during  coughing.  The  examination  should  not  cease  without 
sufficiently  forcible  respiratory  efforts  on  the  part  of  the  infant. 
Prolonged  expiration  and  bronchial  breathing  are  obtained  when  the 
area  of  the  pneumonia  is  recent.  Vocal  fremitus  may  be  heard 
while  the  child  is  crying,  over  larger  areas  of  consolidation.  The 
examiner  must  not  fa'l  to  use  a  stethoscope  with  a  small  bell,  and 


366  DISEASES  OF  CHILDREN. 

must  not  omit  in  his  search  the  axillary  region,  for  the  first  signs  are 
often  found  there. 

Percussion. — Light  percussion  is  a  desideratum.  Dullness  may  be 
appreciated  if  present  and  points  to  consolidation.  Areas  giving  a 
hyperresonant  note  are  obtained  over  portions  of  the  lung  in  which  a 
compensatory  emphysema  has  occurred. 

The  Important  Symptoms  in  Detail.  Temperature. — As  a  rule, 
the  temperature  is  high  in  the  beginning,  103°  to  104°  F.,  although 
periods  of  remission  are  not  uncommon.  The  disease  ends  by  lysis 
and  the  curve  shows  the  gradual  return  to  the  normal.  No  typical 
temperature  curve  can  be  presented  because  of  the  intermittent  and 
remittent  character  of  the  fever.  Sudden  high  rises  may  indicate  a 
complication  or  an  added  area  of  pneumonia.  Marasmic  infants 
frequently  are  seen  with  little  or  no  fever,  or  they  may  even  have  a 
subnormal  temperature. 

Respirations. — The  normal  ratio  of  pulse  and  respirations,  1  to  3, 
or  1  to  4,  may  be  so  far  disturbed  as  to  reach  1  to  2.5  or  1  to  2.  The 
severity  of  the  dyspnea  can  be  judged  by  the  amount  of  recession  at 
the  sternal  space  and  diaphragmatic  attachments.  The  breathing 
may  be  irregular  or  simulate  the  Cheyne-Stokes  type.  Coughing  or 
crying  markedly  accelerates  the  respirations,  and  if  pain  is  present  it 
is  increased.  The  expiratory  grunt  is  almost  pathognomonic.  It  is 
produced  in  early  life  by  only  three  conditions,  namely,  pneumonia, 
pleurisy,  and  a  very  acute  indigestion.  In  rachitic  children  the 
respirations  are  especially  increased  and  extremely  shallow. 

Heart  and  Pulse. — The  pulse  is  small  and  frequent.  When  the 
temperature  is  high  the  pulse  may  be  as  rapid  as  180  to  200.  Its 
numerical  value  is  not  of  as  much  moment  as  the  character  of  the 
pulse  compared  to  the  action  of  the  heart.  The  second  sound  is  often 
accentuated,  and  anemic  murmurs  are  heard  during  convalesence. 

Digestive  Tract. — Especially  to  be  feared  is  the  distention  of  the 
abdomen  with  gas.  The  meteorism  impedes  the  movements  of  the 
diaphragm  and  adds  greatly  to  the  discomfort  of  the  infant.  Vomit- 
ing is  often  one  of  the  initial  symptoms.  Diarrhea  is  more  frequent 
in  the  nursling,  while  constipation  is  the  rule  with  the  artificially  fed. 

Occasionally  stupor  is  seen  from  the  first  day  of  the  disease.  A 
convulsion  may  usher  in  the  disease  or  purposeless  movements  may 
appear  at  any  time  in  its  course.  Meningitis  may  be  in  consequence 
suspected.  True  symptoms  of  cerebral  involvement  may  precede  a 
fatal  termination.  The  ear  should  be  examined  in  suspected  casesj 
and  lumbar  puncture  made  for  purposes  of  verification. 

Clinical  Forms  of  the  Disease. — Disseminated  bronchopneumonia 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  367 

is  the  form  in  which  there  are  small  areas  scattered  over  diflferent 
parts  of  the  lung.  They  do  not  coalesce,  and  varying  physical  signs 
are  found  in  the  several  patches.  The  asthenic  form  is  frequent  in 
marasmic  or  rachitic  infants,  and  it  generally  accompanies  a  gastro- 
intestinal infection.  There  is  little  or  no  fever  in  this  type,  and  the 
course  is  protracted  and  often  ends  in  death. 

Bronchopneumonia  Complicating  the  Infectious  Diseases. — With 
Pertussis. — To  the  symptoms  of  bronchitis  present  are  added  the 
objective  signs  of  a  pneumonia  usually  of  the  disseminated  type. 
The  temperature  rises  abruptly  and  often  to  105°  F.  The  dyspnea 
is  marked  and  cyanosis  appears  early.  The  complication  seriously 
affects  the  prognosis.  Tuberculosis  may  follow  in  its  wake  if  the 
child  recovers.  The  course  is  usually  long  and  tedious,  remissions 
being  very  common.  During  the  course  of  the  pneumonia  the  spas- 
modic or  paroxysmal  character  of  the  cough  is  not  so  marked  as  in 
uncomplicated  pertussis. 

With  Measles. — If,  after  the  eruption  of  measles  when  the  fever 
has  subsided,  there  is  an  abrupt  rise  of  temperature  and  on  physical 
examination  there  are  found  crepitant  and  subcrepitant  rales  over 
localized  areas,  bronchopneumonia  may  be  diagnosticated.  The  cough 
is  increased;  it  is  more  frequent  and  dyspnea  is  more  marked.  The 
pulse  and  respirations  are  increased.  The  somnolent  and  apathetic 
state  is  again  present. 

With  Diphtheria. — The  pneumonia  is  more  apt  to  occur  in 
cases  having  laryngeal  involvement,  especially  those  which  have  neces- 
sitated operative  interference.  It  is  one  of  the  commonest  causes  of 
death  after  intubation.  Bronchiectasis  or  pulmonary  abscess  may 
develop  in  the  more  chronic  forms. 

W^iTH  Other  Exhausting  Diseases. — As  a  terminal  infection, 
bronchopneumonia  may  occur  in  a  variety  of  diseases  common  to  child- 
hood, more  especially  those  that  are  of  bacterial  origin,  such  as  typhoid 
and  gastroenteritis.  Where  a  general  sepsis  is  present,  it  is  sometimes 
only  discovered  at  necropsy. 

Complications. — As  has  been  stated  above,  the  disease  is  in  it- 
self mainly  secondary  to  some  other  process.  During  its  course  there 
may  develop  an  involvement  of  the  ear,  heart,  peritoneum,  pleura,  or 
meninges.  Following  cases  of  delayed  resolution,  brochiectatic 
cavities,  abscesses,  and  fibroid  changes  may  develop. 

Differential  Diagnosis. — ^From  acute  bronchitis  it  may  be  dis- 
tinguished by  the  milder  sj^mptoms,  the  lower  grade  of  temperature 
and  pulse,  and  the  less  disturbed  pulse-respiration  ratio.  No  localized 
area  of  bronchial  breathing,   bronchophony,  or  fine  crepitant  rales 


368  DISEASES  OF  CHILDREN. 

will  be  found.  Instead  there  will  only  be  present  numerous  coarse 
and  fine  bronchial  rales. 

From  Lobar  Pneumonia. — If  occurring  in  an  infant,  and  there 
is  a  history  of  a  primary  infectious  disease,  bronchopneumonia  is 
rather  to  be  suspected.  In  the  lobar  type  the  temperature  is  more 
constantly  high  and  drops  by  crisis,  while  the  course  is  invariably 
shorter.  The  physical  signs  may  not  be  distinctive  until  consolida- 
tion has  taken  place.  Leukocytosis  is  higher  and  persists  until  the 
temperature  falls  at  crisis. 

From  Tuberculosis. — A  bronchopenumonia  of  long  duration 
is  often  regarded  as  a  tuberculous  process.  It  is  to  be  differentiated 
by  the  tuberculous  aspect  of  the  child,  the  greater  wasting  and  possibly 
by  the  signs  of  tuberculosis  elsewhere.  The  various  tests  described  on 
page  54  should  be  made  as  an  aid  to  the  diagnosis. 

Course  and  Prognosis. — ^The  course  varies  from  two  to  six  weeks, 
as  a  rule,  and  only  rarely  ends  by  crisis,  lysis  being  the  rule.  A 
pneumonia  superimposed  on  gastroenteritis  or  other  debilitating 
diseases  is  apt  to  be  prolonged  and  to  leave  the  child  in  an  extremely 
emaciated  and  asthenic  condition.  This  is  always  a  very  serious 
disease.  The  prognosis  is  always  unfavorably  influenced  when  it 
complicates  poorly  nourished  infants  with  infectious  or  constitutional 
diseases.  The  younger  the  child  the  more  unfavorable  the  prognosis. 
Artificially  fed  infants  in  institutions  and  those  with  rickets  or  whoop- 
ing cough  must  be  regarded  as  especially  unfavorable.  The  signs  upon 
which  the  practitioner  may  base  a  favorable  prognosis  are  undisturbed 
heart  sounds,  absence  of  marked  dyspnea,  willingness  to  take  nourish- 
ment, and  undisturbed  gastrointestinal  tract.  On  the  contrary,  if 
vomiting  and  diarrhea,  irregular  breathing,  meteorism,  and  cerebral 
symptoms  develop,  the  outlook  points  to  a  fatal  issue. 

Treatment. — The  high  mortality  of  this  disease  will  be  reduced  if 
the  disease  is  treated  rationally.  The  vital  resistance  of  the  infant 
must  be  supported  or  increased  so  that  the  self-limited  disease  may 
terminate  favorably.  Fresh  air,  proper  diet,  hydrotherapy,  and 
stimulation,  when  appropriately  used,  will  conserve  the  resisting 
powers. 

Aerotherapy. — The  patient  should  be  placed  in  its  crib  in  a  large 
sunny  room,  the  widows  of  which  are  opened  to  admit  an  abundance 
of  fresh  air.  Light  and  warm  clothing  should  be  worn  in  the  colder 
months,  hot-water  bags  or  an  electric  thermophor  being  placed  at 
the  child's  feet  if  the  extremities  are  cold.  A  screen  may  be  used  to 
shield  the  patient  from  a  direct  draught. 

The  diet  should  be  a  modification  of  the  previous  feedings.     With 


DISEASES  OF  THE  LUNGS  AND   PLEURA.  369 

the  breast  fed,  reduce  the  intervals  and  give  water  before  nursing. 
The  food  of  the  artificially  fed  should  be  reduced  with  gruel.  Older 
children  are  allowed  milk,  gruels,  broths,  albumin  water,  and 
orangeade. 

The  temperature  should  be  controlled  by  hydrotherapeutic 
measures  if  it  is  causing  unrest,  insomnia,  or  cerebral  symptoms.  A 
temperature  of  104°  F.  in  one  infant  may  cause  less  distress  than  a  tem- 
perature of  101°  F.  in  another  child.  A  daily  cleansing  bed-bath  should 
be  given  in  all  cases.  The  milder  measures  for  the  reduction  of 
temperature  should  be  first  attempted — for  example,  an  alcohol 
sponge-bath  (one  part  to  four)  will  usually  reduce  the  temperature  a 
degree  or  two,  and  also  has  a  tonic  effect  upon  the  patient.  The 
water  may  be  luke-warm,  but  its  alcoholic  strength  may  be  increased 
if  the  desired  effect  is  not  obtained.  The  naked  infant  is  wrapped 
in  a  flannel  blanket  and  one  portion  of  the  body  after  another  is 
sponged,  and  by  gentle  friction  the  liquid  made  to  evaporate,  and 
thus  the  cooling  effect  is  obtained.  Such  a  bath  should  take  from  ten 
to  twenty  minutes  and  is  often  followed  by  relaxation  and  a  refreshing 
sleep.  Compresses  wrung  out  of  water  at  90°  F.  may  be  placed  about 
the  chest  and  renewed  hourly  almost  without  disturbing  the  patient. 
The  cold  pack  will  be  required  in  sthenic  cases  with  high  temperature 
and  delirium.  Ice-bags  to  the  head,  w^hile  effective  in  reducing  tem- 
perature, are  dangerous  unless  cautiously  employed  under  the  direct 
supervision  of  a  competent  nurse.  Weak,  badly  nourished  infants 
or  those  wuth  a  subnormal  temperature  are  preferably  given  a  hot 
mustard  bath  with  the  water  at  105°  F.  A  cheese-cloth  bag  containing 
an  ounce  of  mustard  is  drawn  through  the  water  and  the  infant  is 
removed  when  the  skin  reddens  from  the  counterirritant. 

Local  Applications. — Mustard  pastes  are  especially  effective  in 
the  beginning  of  the  disease  and  should  be  applied  directly  over  the 
affected  area  in  the  strength  of  one  part  mustard  to  six  or  seven  of 
flour.  Directions  should  be  given  as  to  the  size  and  frequency  of  the 
application.  When  the  skin  is  well  reddened  the  application  should 
be  removed.  If  the  area  becomes  blanched  within  four  hours  a 
second  application  may  be  made.  Warm  poultices  and  oiled  silk 
jackets  are  only  mentioned  to  be  deprecated. 

Medication. — No  drug,  however  harmless,  should  be  prescribed 
without  a  distinct  indication.  The  symptoms  will  in  greater  part  be 
relieved  by  sponging  and  local  applications.  If  the  bowels  are  con- 
stipated an  initial  calomel  purge  in  divided  doses  or  an  enema  may 
be  given.  Sedatives  for  the  cough  as  a  routine  measure,  especially  in 
the  form  of  syrups  tend  only  to  produce  fermentation  and  retard 
24 


370  DISEASES  OF  CHILDREN. 

progress.  A  stimulating  expectorant  in  the  form  of  the  ammonia 
preparations,  as  the  aromatic  spirits  or  the  Liq.  ammoniae  anisati, 
will  promote  freer  secretion  if  required  and  also  tend  to  support  the 
heart.  A  harassing  purposeless  cough  which  prevents  sleep  can  be 
profitably  controlled  with  small  doses  of  Dover's  powder  (h  gr.  to  one- 
year-old  child,  q.  4  h.). 

Judicious  stimulation  of  the  heart  is  one  of  the  most  essential 
parts  of  the  treatment.  The  physician  must  be  guided  by  the  action 
of  the  heart  when  the  child  is  quietly  sleeping.  A  rapid  feeble  pulse 
rate,  weakness  of  the  heart  sounds,  and  signs  of  failing  compensation 
are  indications  for  drug  assistance. 

Strychnin  well  meets  many  of  these  indications,  unless  the  nervous 
symptoms  are  a  prominent  feature.  One  three-hundredth  of  a  grain 
may  be  alternated  with  another  suitable  cardiac  stimulant  every  four 
hours  for  a  year-old  infant.  The  tincture  of  strophanthus  in  drop  doses 
every  three  to  four  hours  is  an  effective  remedy  having  no  ill  effects 
on  the  digestive  tract.  Alcohol  in  the  form  of  brandy,  if  used  at  all, 
should  be  given  well  diluted,  but  never  continued  for  any  length  of 
time,  as  nausea  or  vomiting  almost  invariably  results.  If  the  right 
heart  needs  assistance,  nitroglycerin  preferably  given  in  the  form 
of  the  spirits  of  glonoin  (gr.  ^^^  to  a  year-old  child)  meets  this  in- 
dication. It  must  be  frequently  given,  usually  every  two  hours. 
Camphor  (grs.  1  to  10  minims  of  sterile  olive  oil)  should  be  used  hypo- 
dermatically  in  desperate  cases.  If  the  stomach  does  not  retain  food 
or  medication,  the  needle  must  be  used  if  stimulation  is  imperative. 

Hypostatic  Pneumonia. 

This  form  of  pneumonia  is  found  as  a  secondary  affection  in 
many  poorly  nourished  children,  and  especially  in  those  who  are 
brought  to  children's  hospitals  for  treatment.  It  is  no  doubt  a  result 
of  lowered  vital  resistance.  The  postmortem  examination  shows  an 
area  of  dark  solid  or  semisolid  lung  tissue  along  the  posterior  borders 
of  the  lung;  on  cut  section  it  is  dark,  grumous,  and  edematous.  A 
serosanguinolent  fluid  exudes  on  pressure.  The  symptoms  are  those 
of  a  low-grade  pneumonia. 

Treatment. — Combat  the  accompanying  asthenia  with  stimulants, 
such  as  strychnia  and  nitroglycerin,  and  treat  the  original  condition. 
All  such  children  need  particularly  to  be  removed  for  a  few  hours 
from  the  sick-room  and  their  position  in  the  crib  is  to  be  frequently 
changed.  They  often  breathe  better  if  the  chest  is  elevated  on  a 
pillow. 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  "     371 

Lobar  Pneumonia. 
(Croupous  Pneumonia.) 

A  pneumonia  affecting  a  lobe  or  a  considerable  part  of  a  lobe 
and  is  caused  by  the  diplococcus  of  Frankel. 

Etiology. — This  form  is  more  commonly  seen  in  children  of  two  or 
more  years  of  age  and  is  rarely  secondary,  as  is  bronchopneumonia. 

Pathology. — The  apices  are  in  our  experience  more  frequently 
first  affected  in  children,  and  then  the  bases.  The  disease  passes 
through  the  four  stages  just  as  it  does  in  adults;  i.  e.,  congestion, 
red  and  gray  hepatization,  and  resolution. 

Symptomatology. — The  onset  is  sudden,  most  frequently  with  a 
chill  or  chilly  feelings  or  convulsions,  followed  rapidly  by  high  fever 
and  rapid  breathing.  In  some  cases  the  nervous  symptoms  mask 
the  pulmonary  condition,  simulating  meningitis.  The  temperature 
rises  to  103°  or  105°  F.,  and  remissions  are  only  slight  and  usually  take 
place  in  the  morning.  In  severe  cases  the  prostration  is  complete, 
with  delirium  and  semicoma.  The  child  refuses  food,  is  thirsty, 
and  ma}'  complain  of  pain  on  coughing,  or  of  abdominal  pain.  The 
cough  may  be  slight  or  even  absent  for  a  few  days,  but  toward  the  end 
is  quite  marked.  In  older  children  rusty  sputum  is  sometimes  ob- 
served. The  disease  ends  by  a  crisis,  but  this  is  not  always  sharply 
defined.  It  may  end  also  by  lysis,  especially  in  those  children  who 
have  previously  been  enfeebled. 

Physical  Signs. — Inspection.  Flushed  face,  dilating  alae  nasi,  and 
rapid  respirations. 

Auscultation. — Bronchial  breathing  is  noted  in  the  early  stages  and 
later  fine  subcrepitant  rales;  when  resolution  takes  place,  broncho- 
vesicular  breathing  and  many  moist  rales  may  also  be  present. 

Percussion. — Dullness  over  the  affected  area  diminishing  as  the 
disease  progresses  and  resolution  takes  place. 

Palpation. — Increased  fremitus. 

Complications. — More  or  less  pleurisy  of  a  dry  character  is  present 
in  nearly  every  case.  Meningitis  is  often  secondary  in  the  grave  or 
fatal  cases.  Otitis  is  not  rare,  while  pericarditis  and  peritonitis  are 
sometimes  seen.     Empyema  should  always  be  considered. 

Diagnosis. — The  sudden  onset,  more  constant  high  fever  and  phy- 
sical signs  of  consolidation  differentiate  it  from  a  bronchopneumonia. 
A  centralized  pneumonia  is  often  puzzling  and  causes  a  suspicion  of 
typhoid  fever  or  malaria.  A  blood  examination  will  then  assist  the 
diagnosis.  In  the  central  pneumonia  the  process  is  enclosed  in 
healthy  lung  tissue,  and  the  physical  signs  may  not  appear  for  several 


372  DISEASES  OF  CHILDREN. 

days,  but  the  rational  signs  plus  the  fairly  characteristic  symptoms 
will  fix  the  diagnosis.  The  pain  referred  to  the  abdomen  has  led  to  a 
mistaken  diagnosis  of  appendicitis.     Examine  the  lungs. 

Prognosis. — The  prognosis  is  very  good.  Ninety-six  per  cent,  of 
all  cases  recover. 

Treatment. — This  has  already  been  spoken  of  under  Broncho- 
pneumonia. It  is  essentially  the  same,  but  may  be  more  vigorously 
pursued,  as  the  cases  are  generally  of  a  more  sthenic  type.  Com- 
plications by  extension  into  the  ear  must  be  guarded  against.  Re- 
peated examinations  of  the  ear-drums  may  be  necessary. 

Pleurisy. 

Dry  Pleurisy. — This  is  an  inflammation  of  a  localized  area  of 
the  pleural  surface,  usually  in  conjunction  with  a  pneumonic  process, 
over  infarcts  or  extension  from  a  tuberculous  pneumonia.  These 
lesions  are  seen  frequently  postmortem;  the  pleural  surface  is  found 
to  be  dull  and  lusterless  with  the  adhesions  firm  or  fibrinous. 

Symptomatology. — To  these  adhesions  the  pain  accompanying  a 
pneumonic  process  may  be  ascribed  (a  pleuritic  friction  rub  is  heard 
on  auscultation  over  the  consolidated  area). 

The  pain  is  sharp  and  lancinating,  and  usually  produced  or  noticed 
after  coughing.  In  older  children  it  is  evidenced  at  the  end  of  a  deep 
inspiration. 

Treatment. — Outlined  under  Serous  Pleurisy. 

Serofibrinous  Pleurisy. 

This  form  also  results  from  extension  of  infection  from  a  tubercu- 
lous or  pneumonic  process.  The  fluid  is  usually  found  to  be  sterile 
on  ordinary  culture  media,  but  in  cases  in  which  perfected  methods 
have  been  employed  the  tubercle  bacilli  may  be  found. 

Infants  rarely  have  this  form  of  plurisy;  it  is  more  commonly 
found  after  two  years  of  age.  The  weight  of  opinion  inclines  to  the 
belief  that  previously  infected  bronchial  lymph-glands  are  the  source 
of  infection. 

Pathology. — On  the  surface  of  the  pleura  is  found  a  fibrinoplastic 
exudate,  sometimes  thick,  but  usually  thin  and  soft.  The  fluid 
which  exudates  is  yellow  or  yellowish-green  in  color.  The  lung  may 
be  found  collapsed  in  whole  or  in  part.  Sacculated  effusions  of  serous 
fluid  are  not  as  common  as  the  purulent.  The  bases  of  the  lung  form 
the  common  site;  occasionally  both  bases  are  affected  simultaneously. 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  373 

Symptomatology. — For  several  days  there  is  fever,  cough,  chilli- 
ness and  more  or  less  pain  referred  to  the  chest.  Gradually  the  child 
is  seen  to  play  less,  is  listless  and  apathetic.  The  temperature  is  irreg- 
ular, fluctuating  from  101°  to  102°  F.  Difficult  breathing  is  now  ap- 
parent. The  pain,  it  should  be  recollected,  may  be  referred  to  the 
abdomen.  Headache,  constipation,  and  coated  tongue  are  usual 
manifestations.  The  respirations  and  pulse  are  accelerated,  but  the 
ratio  is  not  seriously  disturbed  unless  the  effusion  is  large.  In  the 
latter  event  pain  is  usually  diminished  or  absent.  Loss  of  flesh  is  now 
apparent,  dyspnea  is  marked,  and  the  child  prefers  to  lie  on  the  affected 
side. 

Physical  Signs. — Inspection.  Movement  may  be  impaired  if  the 
effusion  is  large.  The  cyrtometer  may  show  greater  measurement  on 
the  affected  side. 

Palpation. —  Vocal  fremitus  is  diminished  in  large  collections. 

Auscultation. — The  respiratory  murmur  is  diminished  and  bron- 
chial breathing,  distant  in  character,  may  be  heard,  and  over  the  base 
all  breath  sounds  may  be  absent.  The  breath  sounds,  if  heard  at  all, 
diminish  from  the  spine  toward  the  axilla.  Friction  rales  may  be 
heard  at  or  above  the  fluid  in  older  children.  The  vocal  resonance  is 
diminished  over  the  fluid  itself,  but  does  not  assume  the  character- 
istics observed  in  adults. 

Percussion. — A  dull  or  dull  to  flat  note  is  elicited  by  percussion 
together  with  a  sense  of  resistance  to  the  percussing  finger.  Above 
the  fluid  a  tympanitic  note  may  be  heard. 

Large  effusions  may  displace  the  heart,  liver  and  spleen  especially 
in  older  subjects.  Aspiration  confirms  the  diagnosis.  (See  article  on 
Empyema,  p.  374.) 

Prognosis. — The  fluid  has  a  tendency  to  spontaneous  absorption, 
provided  purulent  changes  do  not  take  place,  and  death  rarely  results 
from  the  effusion  itself.  The  prognosis  is  unfavorably  influenced  if  the 
fluid  is  due  to  a  tuberculous  focus. 

Treatment. — Rest  in  bed  is  imperative.  If  the  fluid  is  small  in 
amount,  free  bowel  action,  plus  the  use  of  diuretics  as  the  Liq.  ammonii 
acetatis  with  a  moderately  dry  light  diet  may  suffice  for  a  cure.  In 
large  effusions,  aspirate  at  once,  then  follow  the  plan  outlined  above. 
The  Liq.  ferri  et  ammonii  acetatis  serves  very  well  as  an  after-treatment 
combined  with  a  life  in  the  sunlight  and  fresh  air.  Aspiration  should 
be  performed  according  to  the  directions  given  under  Empyema  on  page 
374.  If  the  effusion  is  copious  a  Potain  aspirator  or  the  siphonage 
method  advocated  by  Huber  will  be  found  advantageous. 


374  DISEASES  OF  CHILDREN. 

Empyema. 

Empyema  is  known  to  be  much  more  frequent,  both  relatively 
and  absolutely,  in  infancy  and  childhood  than  in  adult  life.  Statistics 
show  us  that  40  per  cent,  of  pleurisies  in  infancy  and  childhood  are 
purulent,  while  only  5  per  cent,  result  in  a  suppurative  pleuritis  in 
adults.  Yet  in  spite  of  this  fact  it  has  been  mainly  studied  patholog- 
ically and  clinically  from  adult  life. 

The  great  majority  of  cases  of  empyema  follow  pneumonia  in 
children,  either  the  form  known  as  pleuropneumonia  or  broncho- 
pneumonia. Although  the  infectious  diseases  and  pyemia  may  be 
complicated  by  it,  some  inflammatory  process  in  the  lung  or  pleura 
has  generally  preceded  the  suppurative  process. 

The  pneumococcus  we  find  present  in  the  greater  number  of  cases 
in  almost  pure  culture.  The  staphylococcus  and  streptococcus  occur 
in  cases  from  which  thin  pus  with  little  fibrin  is  withdrawn.  We  are 
as  yet  uncertain  as  to  the  number  of  cases  due  to  the  tubercle  bacillus; 
as  this  organism  is  difficult  to  find  in  the  exudate,  and  is  often  reported 
as  absent  when  the  subsequent  course  would  clinically  stamp  the 
case  as  of  the  tuberculous  variety.  Bovaird  believes  that  six  per 
cent,  of  all  cases  are  tuberculous. 

The  pus  found  in  the  average  case  of  empyema  is  quite  thick, 
creamy  and  odorless,  with  masses  of  fibrin  of  varying  consistency 
floating  in  it.  The  fluid  exudes  quite  slowly  at  first,  and  there  is  in  the 
beginning  an  attempt  made  by  nature  to  wall  oflf  this  fluid  by  fine 
adhesions,  with  the  result  that  small  pockets  or  sacculations  are 
formed;  as  the  fluid  accumulates  in  greater  quantity,  these  septa  are 
broken  down  and  merged,  and  thus  the  fluid  may  fill  the  entire  pleural 
cavity. 

Sacculation  is  frequent  in  children  and  it  is  important  to  be  able 
to  recognize  the  condition  at  this  stage,  and  treat  the  case  early  before 
much  damage  has  been  done.  The  fluid  in  cases  of  pleurisy  with 
effusion  slowly  becomes  slightly  turbid,  then  seropurulent,  and  finally 
assumes  pure  pus  characteristics;  this  change  being  accompanied  by 
a  corresponding  increase  in  the  number  of  bacteria  present. 

A  study  of  the  charts  of  the  empyema  cases  at  the  Post-Graduate 
Hospital  in  New  York  shows  that  the  empyema  develops  about  the 
fourth  week  after  pneumonia,  and  that  the  average  amount  of  pus  is' 
small  (5  to  8  oz.).  The  most  frequent  complications  were  peritonitis, 
meningitis,  pericarditis,  and  sepsis. 

Symptomatology. — If,  in  a  case  which  has  recovered  from  a  pneu- 
monic process  or  from  an  infectious  disease,  there  is  not  a  steady  im- 


DISEASES  OF  THE  LUNGS  AND   PLEURA.  375 

provement  in  physical  well-being,  but  instead  a  low-grade  temperature, 
with  increased  number  of  respirations,  accompanied  by  a  slight  hacking 
cough,  pallor,  sweating  of  the  head,  steady  emaciation,  and  a  marked 
leukocytosis,  our  suspicions  should  be  directed  to  fluid  in  the  chest. 

In  spite  of  these  warning  rational  signs  there  is  probably  no  other 
equally  great  pathological  change  anywhere  in  the  body  so  often  un- 
suspected or  overlooked. 

The  physical  signs  of  fluid  in  the  chest  of  infants  and  children 
differ  grossly  from  those  of  the  adult.  In  the  examination  the  pos- 
sibility of  encapsulated  or  sacculated  effusions  must  be  kept  in  mind 
which,  as  has  been  pointed  out,  may  contain  but  little  pus  and  still 
give  marked  subjective  symptoms.  In  infants  the  chest  may  contain 
fluid  and  we  may  still  obtain  normal  or  practically  normal  breath 
and  voice  sounds. 

Confirmatory  physical  signs  above  the  fluid,  at  the  level  of,  and 
over  the  fluid  cannot  always  be  obtained  in  young  patients.  Ellis' 
curve  and  obliteration  of  Traubes'  space  cannot  be  depended  upon 
for  assistance.     Skoda's  resonance  may  or  may  not  be  present. 

The  main  signs  upon  which  reliance  must  be  placed  are  marked 
dullness  or  flatness  on  percussion  over  any  area  usually  resonant,  bron- 
chial breathing,  and  marked  resistance  to  the  percussing  finger,  as 
distinguished  from  a  corresponding  point  on  the  opposite  side.  These 
physical  signs  coupled  with  the  rational  signs  above  enumerated  should 
be  sufficient  justification  for  the  introduction  of  the  needle.  An 
early  diagnosis  is  of  the  utmost  importance,  and  no  diagnosis  of 
empyema  should  be  regarded  as  complete  without  exploratory  punc- 
ture. If  in  addition  to  these  physical  signs  we  can  elicit  bronchial 
breathing  over  the  area  of  flatness;  relative  immobility  of  the  affected 
area  and  bulging,  with  displacement  of  the  apex  beat — then  omission 
to  puncture  would  be  unjust  to  the  patient. 

Exploratory  Puncture. — The  exploring  syringe  and  needle  should 
be  of  good  caliber  and  length,  as  the  pus  may  be  thick  and  contain 
clots  of  fibrin.  After  proper  sterilization  of  the  syringe  it  should  be 
tested  to  ascertain  if  it  is  still  in  good  working  order.  The  skin  hav- 
ing been  thoroughly  cleansed  over  the  affected  area,  the  needle  can 
be  inserted  somewhat  above  the  lowest  point  of  flatness.  If  the 
whole  side  is  involved  we  can  select  the  most  favorable  points;  viz., 
in  the  sixth  interspace  in  the  posterior  axillary  line  on  the  left  side 
and  the  fifth  interspace  on  the  right  side.  If  we  keep  in  mind  that 
the  diaphram  rises  higher  in  children  than  in  adults  and  that  the 
liver  must  be  avoided  on  the  right  side  we  have  a  fair  field  for 
exploration. 


376 


DISEASES  OF  CHILDREN. 


With  the  child  held  in  the  upright  position,  and  its  arm  extended 
above  its  head,  we  can  thrust  the  needle  directly  forward — noting  at 
the  same  time  the  amount  of  force  necessary  to  penetrate  the  pleura 
and  partly  withdraw  the  plunger.  If  no  fluid  appears  point  the 
needle  upward,  and-  then  if  necessary  downward,  and  you  will  have 
explored  the  suspected  area  thoroughly  and  avoided  the  possibility 
of  escaping  encapsulated  pus  or  penetrating  a  thick  fibrinous  mass. 
This  method,  if  a  strong  needle  is  used,  presents  no  dangers,  and  saves 
the  child  from  repeated  explorations,  when  we  feel  morally  certain 
that  fluid  is  present  but  fail  to  get  it  with  the 
syringe. 

If  possible,  examine  the  exudate  for  bacteria, 
as  the  bacteriological  findings,  coupled  with  the 
duration  of  compression,  the  amount  of  pleural 
thickening  and  ability  of  the  patient  to  resist  the 
effect,  will  determine  the  prognosis. 

When  a  clear,  strong-colored  fluid  is  with- 
drawn we  can  afford  to  wait  and  watch  for  signs 
of  recession  of  the  fluid.  If  this  does  not  occur,  or 
the  temperature  curve  later  shows  septic  character- 
istics, puncture  again,  and  the  fluid  will  now  proba- 
bly show  purulent  changes.  When  the  first  ex- 
ploration shows  a  seropurulent  or  purulent  dis- 
charge operative  interference  should  not  be  delayed. 
Treatment. — Bouveret  in  his  classical  treatise  in  1888,  of  nine 
hundred  pages  on  Empyema,  still  advocated  aspiration  as  the  treat- 
ment in  children.  From  two  to  thirty  aspirations  were  made  (in  one 
case  122),  which  indeed  led  to  cures,  but  the  mortality  was  high. 
This  form  of  treatment  is  now  rarely  resorted  to  and  we  believe  it 
finds  few  advocates.  We  would  not  treat  an  acute  abscess  by  aspira- 
tion, and  what  is  an  empyema  but  a  pleural  abscess?  Aspiration, 
then,  should  be  employed  for  temporary  relief  of  dyspneic  symptoms 
only.  Incision  and  drainage  aseptically  performed  under  light 
general  or  local  anesthesia  gives  better  results,  and  this  method  is 
sometimes  used.  The  operation  of  rib  resection  is  preferable  in  all 
cases  of  empyema  except  in  very  young  infants  whose  physical  con- 
dition warrants  any  operative  interference.  The  general  subperiosteal 
operation  of  the  eighth  or  ninth  rib  in  the  postaxillary  line  is  no  mai'e 
dangerous  than  incision  and  can  be  as  quickly  performed,  especially 
when  we  recollect  that  in  the  former  operation  we  are  often  obliged 
to  pass  the  finger  through  the  incision  to  free  the  fibrinous  masses. 
By  resection  we  secure  ample  drainage  space,  are  not  hindered  with 


Fig.  104.— Aspi- 
rating syringe  suita- 
ble for  thoracentesis. 


DISEASES  OF  THE  LUNGS  AND   PLEURA. 


377 


clogged  tubes,  and  what  is  most  important  we  hasten  the  time  of 
recovery  of  the  patient.  No  permanent  deformity  results,  as  it  is 
necessary  to  remove  only  one  inch  of  the  rib  and  the  periosteum  is 
preserved.  The  mortality  is  reduced  also  to  one  in  seven.  Instead 
of  the  double  drainage-tube  the  writer  uses  the  spool  tube  (see 
Fig.  105)  of  suitable  size  for  the  patient.  This  has  the  advantage  of 
being  least  irritating  to  the  pleural  surfaces,  and  in  action  simulating 
a  valve,  allows  the  lung  to  expand  with  coughing  efforts,  and  further- 
more can  be  easily  cleansed  without  painful  removal.  This  tube 
should  be  removed  as  soon  as  the  dis- 
charge becomes  serous.  The  sinus  will 
then  still  be  fresh  and  tend  to  close,  leav- 
ing surprisingly  little  deformity.  Irriga- 
tion except  in  extremely  fetid  neglected 
cases  is  not  to  be  employed. 

The  dressings  are  pads  of  sterile  gauze 
(not  iodoform  gauze),  applied  over  the 
opening  in  the  tube  and  held  to  the  chest 
by  a  Bender's  elastic  bandage  (in  which 
each  thread  is  a  twisted  one).  This  allows 
freedom  of  chest  movements  of  the  unaffected  side  and  greater  degree 
of  cough  impulse,  thus  favoring  the  expansion  of  the  compressed 
lung.  The  child  should  be  allowed  to  get  up  as  soon  as  possible^  and 
early  encouraged  to  blow  through  some  musical  instrument,  or  to 
make  soap  bubbles.  This  plan,  coupled  with  proper  tonic,  dietetic, 
and  hygienic  treatment  should  give  good  results. 

In  long  standing  or  neglected  cases  of  empyema  in  which  there 
are  many  and  firm  adhesions  with  or  without  collapse  of  the  lung, 
Lloyd  advocates  digitally  breaking  up  all  the  adhesions  and  allowing 
the  lung  on  the  opposite  side  to  inflate  the  collapsed  lung  after  the 
anesthetic  has  been  temporarily  stopped. 


Fig.  105. — Spool  made  of  soft 
rubber  for  drainage. 


Pneumothorax. 

Pneumothorax  or  air  in  the  thoracic  cavity  is  an  exceedingly  rare 
condition  in  early  life.  It  is  usually  tuberculous,  but  may  also 
result  from  traumatism,  foreign  bodies  in  the  bronchi,  rupture  of  a 
bronchiectatic  cavity,  pulmonary  abscess,  empyema,  or  caseating 
lymph  nodes.  Cases  have  also  been  reported  following  pertussis, 
diphtheritic  and  laryngeal  stenosis. 

Symptomatology. — The  symptoms  begin  very  abruptly;  dyspnea, 
cyanosis,  thoracic  pain,  and  a  rapid  thready  pulse  being  the  cardinal 


378'  DISEASES  OF  CHILDREN. 

symptoms.  Percussion  elicits  a  tympanitic  or  hyperresonant  note, 
as  a  rule,  but  a  dull  note  is  occasionally  obtained  if  the  pleura  is 
disturbed.  Vocal  fremitus  is  absent.  Voice  sounds  are  distant,  and 
metallic  succussion  may  be  obtained  over  the  tympanitic  area. 

If  both  air  and  fluid  are  present,  the  viscera  may  be  displaced 
from  their  normal  relations.  We  have  observed  sacculated  pneu- 
mothorax resulting  from  a  pyothorax  in  which  the  onset  was  gradual 
and  the  symptoms  proportionately  less  intense.  : 

Prognosis. — This  is,  as  a  rule,  unfavorable,  owing  to  the  severity 
of  the  underlying  causes. 

Treatment. — Absolute  rest  to  body  in  the  prone  or  semirecumbent 
position  must  be  insisted  upon.  Stimulation  and  chest  strapping  are 
indicated.  The  recent  experiments  with  positive  pressure  and  the 
Sauerbruch  box  for  intrathoracic  operations  offer  some  hope  for 
surgical  procedure  in  these  cases. 

Pulmonary  Abscess. 

This  is  a  rare  condition  resulting  from  the  invasion  of  pyogenic 
bacteria,  following  aspirated  foreign  bodies  in  the  lung,  pneumonia, 
pulmonary  emboli,  or  caseating  lymph  nodes. 

Symptomatology. — The  symptoms  develop  slowly,  following 
what  appears  to  be  a  protracted  convalescence.  Often  they  are  not 
distin-ctive  in  character.  The  emaciation  is  progressive,  the  tempera- 
ture, if  followed  closely,  shows  a  septic  curve.  Profuse  sour  sweating 
is  the  rule.  If  combined  with  the  above  description  we  have  thick 
purulent  sputum  containing  leukocytes  and  elastic  fibers,  and  if  on 
blood  examination,  a  marked  leukocytosis  (50,000  to  60,000  per  cm.)  is 
found,  abscess  of  the  lung  should  be  considered  and  a  diagnosis  made 
by  excluding  tuberculosis,  encapsulated  empyema  and  gangrene  of  the 
lung.     In  selected  cases  surgical  treatment  may  be  of  avail. 

Gangrene  of  the  Lung. 

Pulmonary  gangrene  is  a  rare  condition  in  children,  resulting  from 
pyogenic  bacteria  infecting  a  necrotic  portion  of  the  lung.  It  is 
a  secondary  condition  following  pneumonia,  the  infectious  diseases, 
bronchiectasis,  the  aspiration  of  foreign  bodies,  gangrenous  stomati- 
tis, or  necrosis  of  the  petrous  portion  of  the  temporal  bone.  The. 
diagnosis  is  more  often  made  at  necropsy  than  during  life. 

Diagnosis. — This  is  founded  upon  the  putrid  expectoration  of  a 
dirty  greenish  color,  which  on  examination  is  found  to  contain  shreds 
of  pulmonary  tissue.     The  child's  breath  is  almost  always  offensive. 


DISEASES  OF  THE  LUNGS  AND  PLEURA. 


379 


There  is  progressive  emaciation,  prostration  and  an  irregular  tem- 
perature. The  cough  is  somewhat  paroxysmal,  followed  by  the  expec- 
toration of  a  good  quantity  of  the  characteristic  sputum.  Even 
young  children  will  expectorate  who  are  suffering  with  pulmonary 
gangrene.  Following  the  evacuation  of  the  pus  we  may  be  able  to 
obtaiij  the  cavernous  signs  indicating  a  cavity.  Hemoptysis  sometimes 
follows  after  a  severe  attack  of  coughing. 

Course    and    Prognosis. — The    prognosis    is    invariably    grave. 
Careful  supervision  and  aerotherapy  may  so  far  improve  the  patient's 
general  condition  that  surgical  meas- 
ures   may  be   justifiably  attempted 
with  the  chance  of  a  permanent  cure. 

Treatment. — Until  operative 
measures  can  be  instituted,  forced 
feeding,  stimulation  and  cod-liver  oil 
should  be  used.  Inhalations  of  the 
compound  tincture  of  benzoin,  tur- 
pentine, or  the  oil  of  eucalyptus  will 
mitigate  the  foul  odor. 

Bronchiectasis. 


This  disease  results  from  a 
weakening  of  the  bronchial  wall 
following  a  number  of  pulmonary 
conditions,  the  most  important  of 
which  are  interstitial  pneumonia, 
chronic  bronchitis,  emphysema, 
pulmonary  collapse,  tuberculosis, 
and  foreign  bodies.  The  dilatations 
are  cylindrical  or  sacculated  or  small 
and  diffuse,  and  always  contain  a 
large  number  of  bacteria. 

Symptomatology. — Added  to  the 
symptoms  of  the  underlying  disease, 
or  during  convalescence  therefrom, 
the  patient    begins   to   expectorate 

a  quantity  of  mucopurulent  sputum.  This  cough  is  paroxysmal, 
and  may  be  induced  by  changing  the  position  of  the  patient  from 
the  diseased  to  the  normal  side.  The  collected  sputum  has  a  dis- 
agreeable odor,  is  thin,  grayish-brown,  and  separates  into  a  frothy, 
a  watery,  and  a  granular  layer.     The  fever  is  moderate,  as  a  rule, 


Fig.  106. — Shaded  area  over  a  bron- 
chiectatic  cavity. 


380  DISEASES  OF  CHILDREN. 

although  exacerbations  in  which  may  occur  high  fever,  night-sweats, 
diarrhea  and  pulmonary  hemorrhage,  are  not  uncommon. 

Physical  Signs. — In  a  typical  case,  with  a  well-developed  cavity, 
cavernous  or  amphoric  breathing  with  diminished  vocal  resonance 
may  be  heard  over  the  affected  area.  After  a  free  expectoration,  nu- 
merous coarse  mucous  rales  with  bronchophony  may  be  obtained.  On 
percussion  a  tympanitic  note  is  heard.  Other  evidences  may  be 
found  in  the  clubbed  fingers,  emphysematous  areas,  or  the  develop- 
ment of  a  pulmonary  gangrene. 

Diagnosis. — The  paroxysmal  coughing  occurring  on  change  of 
position,  with  large  quantities  of  expectoration,  with  the  general  con- 
dition not  proportionately  affected,  tend  to  differentiate  it  from  the 
more  acute  condition  of  pulmonary  gangrene  which  causes  marked 
prostration  and  shows  in  the  sputum  portions  of  lung  parenchyma. 
The  needle  may  distinguish  it  from  abscess,  and  the  sputum  examina- 
tion from  pulmonary  tuberculosis. 

Course  and  Prognosis. — The  disease  may  extend  over  many 
months  or  years,  but  complete  recovery  is  extremely  rare.  Complica- 
tions are  easily  acquired  leading  to  a  fatal  result. 

Treatment. — This  should  be  directed  toward  conserving  the 
strength  of  the  patient  by  the  use  of  nourishing  food  and  a  protracted 
sojourn  and  life  in  the  mountains  or  at  the  sea-shore.  The  inhalation 
of  the  volatile  balsams,  such  as  benzoin,  turpentine,  or  eucalyptus, 
are  indicated. 

Quincke's  postural  method,  raising  the  foot  of  the  bed;  or  the 
method  of  expiratory  compression  may  be  used  if  the  cavity  does  not 
thoroughly  empty  itself  after  coughing.  Terpene  hydrate  or  guaiacol 
carbonate  may  be  administered  internally.  Resection  of  the  ribs, 
collapse,  and  drainage  of  the  cavity  has  been  attempted,  but  thus  far 
with  indifferent  results. 


Foreign  Bodies  in  the  Respiratory  Tract. 

Various  objects  may  find  their  way  into  the  larynx,  trachea,  or 
even  into  the  bronchi  by  accidental  inspiration  at  the  time  of  coughing 
or  laughing  when  the  foreign  body  is  in  the  mouth.  Among  the 
objects  we  have  collected  are  an  upholsterer's  tack,  the  glass  eye  of  a 
doll,  fish  bones,  and  a  carrib  bean. 

Symptomatology. — A  sudden  violent  fit  of  coughing  or  choking 
follows  the  aspiration  and  cyanosis  results;  extraordinary  efforts 
are  made  by  the  child  to  breathe.  Occasionally  the  paroxysm  is  so 
slight  as  to  be  mistaken  for  whooping  cough  or  croup.     If  the  object 


DISEASES  OF  THE  LUNGS  AND  PLEURA.  381 

is  sharp,  as  a  fish  bone  for  example,  there  is  some  local  irritation  or 
later  symptoms  of  obstruction.  The  attacks  may  be  followed  by 
periods  of  comparative  quiet  and  rest.  If  the  object  is  small  and 
smooth  and  is  not  coughed  up  at  once,  it  will  eventually  find  its  way 
into  a  bronchus.  It  passes  usually,  owing  to  its  position,  into  the 
right  bronchus. 

Diagnosis. — If  a  history  is  obtained  and  the  symptoms  of  the 
initial  suffocative  attack  are  well  described,  the  diagnosis  maybe  made, 
without  the  knowledge  that  an  object  has  been  aspirated.  When  the 
symptoms  come  on  gradually,  the  diagnosis  may  be  entirely  obscured. 
However,  a  bronchiectatic  cavity,  pulmonary  collapse,  or  abscesses 
should  lead  to  a  careful  investigation  with  this  diagnosis  in  mind. 
An  X-ray  examination  may  materially  aid  in  clearing  up  a  suspected 
case. 

Treatment. — The  finger  or  the  laryngeal  forceps  may  succeed  in 
removing  a  recently  aspirated  object.  If  unsuccessful,  tracheotomy 
may  be  necessary  in  cases  which  would  otherwise  suffocate,  surgical 
measures  for  the  removal  of  the  foreign  body  being  later  employed. 

Direct  laryngobronchioscopy  with  Killian's  instrument  has 
rendered  excellent  service  in  the  removal  of  objects  from  the  bronchi. 

Subphrenic  Abscess. 

This  consists  of  an  accumulation  of  pus  between  the  liver  and 
the  diaphragm  on  the  right  side,  or  between  the  stomach,  spleen,  and 
diaphragm  on  the  left  side.  Downward  extension  of  an  empyema 
through  the  diaphragm  is  the  usual  cause  in  children,  although  it 
may  result  from  intraabdominal  disease.  It  may  also  complicate 
conditions  such  as  appendicitis  and  acute  pneumonia  of  the  septic 
type.  Empyema  is  most  often  diagnosticated  and  the  real  condition 
discovered  at  operation.  Rarely  the  abscess  contains  air,  and 
pyopneumothorax  may  be  suspected. 

Symptomatology. — Beside  the  symptoms  of  the  primary  con- 
dition there  may  be  added  chills,  rapid  pulse,  remittent  fever,  localized 
pain  and  tenderness,  nausea  and  vomiting  with  impeded  respirations. 
In  a  case  seen  by  one  of  us  there  was  a  moderate  amount  of  bulging, 
and  the  liver  was  raised  upward  by  the  pus. 

Treatment. — Prompt  surgical  intervention  with  the  establish- 
ment of  drainage  is  imperative.     The  prognosis  should  be  guarded. 


SECTION  VIII. 
DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


.,.^     ,  .  .,,.,„  CHAPTER   XXVII. 

DISEASES  OF  THE  HEART. 

-  Two  factors  in  early  life  contribute  to  the  vigor  of  the  circulation : 
(1)  The  strength  of  the  heart  muscle  itself  and  the  readiness  with 
which  it  hypertrophies  when  compensation  is  required.  (2)  The 
elasticity  of  the  arteries.  It  is  frequently  not  appreciated  how  im- 
portant a  function  the  arteries  play  in  the  round  of  the  circulation. 
By  their  tonicity  they  aid  the  heart  in  propelling  the  blood  in  a  con- 
stant stream  to  the  various  parts  of  the  body.  If'the  arteries  are 
healthy  and  elastic  great  help  is  thus  afforded  the  heart  in  the  equable 
distribution  of  the  blood.  Even  a  crippled  heart  acts  to  much  better 
advantage  when  the  arteries  can  perform  their  full  share  in  the  work 
of  the  circulation.  Thus  in  early  life  when  the  arteries  are  nearly 
always  in  a  sound  condition,  a  lesion  of  the  heart  may  produce  com- 
paratively little  discomfort,  especially  when  compensatory  hyper- 
trophy is  satisfactory,  as  is  very  apt  to  be  the  case.  When,  however, 
middle  age  approaches  and  a  stiffening  of  the  arteries  ensues  from 
atheromatous  change,  we  will  soon  encounter  dyspnea  and  other 
evidences  of  a  failing  circulation. 

The  blood  pressure  itself,  as  registered  by  the  sphygmomanometer, 
is  lower  in  children  than  in  adults.  The  normal  limits  of  systolic 
pressure  at  different  ages  have  been  given  as  follows: 

Infants,  75  to    90  mm. 

Children,  90  to  110  mm. 

Young  adults,  100  to  130  mm. 

Older  adults,  110  to  145  mm. 

In  a  series  of  observations  made  by  us  at  the  Postgraduate 
Hospital  with  the  Stanton  sphygmomanometer,  the  above  figures 
were  confirmed;  and  observations  were  made  in  diseased  conditions; 
but  while  of  interest,  it  was  not  found  that  this  instrument  was  of 
much  practical  value  in  early  life. 

The  Heart. 

The  infant  has  relatively  a  larger  heart  than  older  children  and 
adults,  and  it   assumes   a   more   horizontal  position  from    a    greater 

382 


DISEASES  OF  THE  HEART.  383 

breadth.  The  apex  beat  in  early  life  is  in  the  fifth  intercostal  space 
and  is  sometimes  a  little  external  to  the  mammary  line.  With  in- 
creasing age  the  apex  beat  deflects  a  little  downward  and  inward, 
reaching  well  within  the  mammary  line. 

Enlargement  of  the  heart  may  be  noted  by  the  position  of  the 
apex  beat  and  by  an  increased  area  of  dullness  on  light  percussion. 
The  space  for  such  percussion  is  situated  between  two  parallel  lines, 
one  line  running  through  the  middle  of  the  sternum  and  the  other 
through  the  left  nipple.  Absolute  heart  dullness  will  be  noted  in  a 
small  triangle  formed  by  the  left  border  of  the  sternum,  the  lower 
border  of  the  fourth  rib  and  a  line  running  from  the  fourth  rib  just 
within  the  mammary  line  to  the  third  costal  cartilage  near  the  left 
border  of  the  sternum.  The  dullness  caused  by  the  left  ventricle  will 
be  marked  out  by  percussing  inward  from  the  mammary  line  over 
the  second,  third,  fourth,  and  fifth  ribs;  that  caused  by  the  right 
ventricle  will  be  located  by  percussing  over  the  fourth  interspace 
beginning  outside  the  right  sternal  line  and  percussing  toward  the 
sternum.  Dullness  caused  by  the  apex  may  be  noted  by  percussing 
from  the  middle  of  the  sternum  along  the  fifth  interspace  to  the  ante- 
rior axillary  line. 

The  heart  beats  with  great  rapidity  in  early  life  and  it  is  often 
puzzling  to  determine  accurately  the  character  of  the  sounds  heard. 
The  pulmonic  second  sound  is  accentuated  throughout  the  early 
years  and  a  certain  arythmia  is  often  observed.  The  pulse  is  fre- 
quently irregular  and  its  rapidity  is  greatly  influenced  by  any  dis- 
turbing conditions,  such  as  crying;  it  also  varies  much  during  waking 
and  sleeping  hours.  The  following  may  be  considered  as  a  fair  general 
average : 

Newborn,  120  to  140. 

First  year,  110 

Second  year,  100 
Fifth  to  eighth  year,       90 

Congenital  Heart  Disease. 

{Cyanosis;  Blue  Disease.) 
New-born  infants  sometimes  exhibit  a  persistent  blueness  due  to 
malformation  of  the  heart.  This  defect  usually  takes  the  form  of 
deficiency  in  the  interauricular  and  interventricular  septa.  The  great 
vessels  may  likewise  be  involved  in  the  malformation,  especially  the 
pulmonary  artery.  Dr.  J.  L.  Smith  found  in  over  half  of  the  162 
cases  he  examined  at  autopsy  that  the  pulmonary  artery  was  absent. 


384  DISEASES  OF  CHILDREN. 

rudimentary,  impervious,  or  partially  obstructed.  He  also  found  the 
following  lesions:  Right  auriculoventricular  orifice  impervious  or  con- 
tracted; orifice  of  the  pulmonary  artery  and  the  right  auriculoventric- 
ular aperture  impervious  or  contracted;  right  ventricle  divided  into 
two  cavities  by  a  supernumerary  septum;  one  auricle  and  one  ventricle; 
a  single  auriculoventricular  opening,  with  interauricular  and  inter- 
ventricular septa  incomplete;  mitral  orifice  closed  or  contracted; 
aorta  absent,  rudimentary,  impervious,  or  partially  obstructed;  aortic 
orifice  and  left  auriculoventricular  orifice  impervious  or  contracted; 
aorta  and  pulmonary  artery  transposed,  the  vena  cava  entering  the 
left  auricle;  pulmonary  veins  opening  into  the  right  auricle  or  into 
the  vena  cava  or  azygos  veins;  aorta  impervious  or  contracted  above 
its  point  of  union  with  the  ductus  arteriosus;  the  pulmonary  artery 
wholly  or  in  part  supplying  blood  to  the  descending  aorta  through  the 
ductus  arteriosus. 

It  is  obvious  that  with  any  of  these  grave  central  lesions  not  only 
the  peripheral  circulation,  but  the  nutrition  as  well  must  suffer.  The 
blood  is  deficient  in  oxygen  and  has  an  excess  of  carbon  dioxid.  The 
blueness  is  most  pronounced  in  the  prominent  parts  of  the  face,  such  as 
the  eye-brows,  cheek-bones,  nose,  and  lips.  The  hands  and  fingers 
are  also  prominently  affected.  The  color  varies  from  a  light  to  a  very 
deep  purple,  the  discoloration  being  aggravated  by  crying  or  other  dis- 
turbing influence. 

While  the  infants  at  birth  may  be  well  developed,  there  are  soon 
evidences  of  failure  of  nutrition,  and  they  are  very  susceptible  to  inter- 
current diseases.  The  action  of  the  heart  is  rapid  and  tumultuous,  and 
the  respiration  is  correspondingly  disturbed.  Various  bruits  are  heard 
upon  auscultation  of  the  heart,  especially  a  systolic  murmur  at  the 
base.  The  right  heart  is  usually  enlarged.  The  infants  suffer  from 
lack  of  sufficient  animal  heat,  and  because  of  this  and  pulmonary  con- 
gestion they  easily  contract  pneumonia.  They  are  apt  to  be  carried 
off  by  any  intercurrent  disease,  and  whooping-cough  is  especially  badly 
borne.  In  a  majority  of  cases  of  congenital  heart  lesion,  the  general 
blueness  is  noted  immediately  or  very  shortly  after  birth.  In  a  minor- 
ity of  cases,  however,  the  lividity  is  not  noticeable  for  an  interval  of 
time,  varying  from  a  few  weeks  to  a  few  months  after  birth.  A  few 
cases  have  been  reported  where  even  a  few  years  have  elapsed  before 
the  blueness  has  become  marked.  The  defect  occurs  more  frequently, 
in  male  than  in  female  infants.  While  this  peculiarity  has  been  noted 
by  most  observers  no  explanation  can  be  given  of  it.  Most  cases  do 
not  survive  the  first  year,  but  occasionally  a  case  will  live  through 
infancy  and  childhood.     It  is  very  rare  to  find  one  surviving  adoles- 


DISEASES  OF  THE  HEART.  385 

cence.  Those  that  survive  infancy  present  a  stunted  appearance, 
although  well  formed  at  birth.  The  chest  becomes  deformed,  with 
a  projecting  sternum,  and  the  fingers  and  toes  bulbous  from  the  slug- 
gish circulation.  Anasarca  may  occur  toward  the  end  of  life,  to  be 
noted  in  the  face  or  ankles,  and  rarely  in  other  parts  of  the  body. 
Death  may  take  place  from  exhaustion,  during  a  paroxysm  of  dyspnea, 
from  convulsions  or  from  a  feeble  resisting  power  in  some  intercurrent 
disease. 

Diagnosis. — In  order  to  distinguish  congenital  from  acquired  heart 
disease,  it  may  be  borne  in  mind  that  the  latter  is  rarely  seen  in  infancy, 
especially  early  infancy.  The  congenital  type  shows  early  and  general 
blueness,  marked  dyspnea,  defective  development  with  bulbous  fingers 
and  toes.  There  is  likewise  no  appearance  or  history  of  rheumatism 
or  acute  endocarditis.  The  commonest  bruit  is  the  loud  murmur  at 
the  base. 

Treatment. — A  general  hygienic  oversight  is  the  most  that  can  be 
accomplished.  The  infants  must  be  kept  warm  and  carefuU}^  fed. 
If  the  blueness  and  dyspnea  become  extreme,  oxygen  may  give  tem- 
porary relief.  Small  doses  of  digitalis  may  be  occasionally  given  as 
an  aid  to  the  circulation. 

Acute  Endocarditis. 

Endocarditis  is  an  inflammation  of  the  endocardium  which  espe- 
cially affects  the  lining  membrane  of  the  valves  and  the  parts  con- 
tiguous to  them. 

Etiology. — The  commonest  cause  is  acute  rheumatism,  and,  in 
some  cases,  it  may  be  the  first  and  even  the  only  manifestation  of  this 
common  disease.  Usually,  however,  it  is  preceded  by  several  attacks 
of  the  mild  form  of  rheumatism  seen  in  early  life.  It  is  also  not  in- 
frequently seen  in  connection  with  chorea.  The  latter  disease  may 
alone  be  responsible  for  endocarditis  or  it  may  be  associated  with 
rheumatism,  the  two  conditions  either  preceding  or  following  the 
heart  attack.  Roger  considers  that  rheumatism,  chorea  and  endo- 
carditis are  frequently  manifestations  of  the  same  underlying  patho- 
logical condition.  Any  infectious  disease  may  attack  the  endocardium, 
especially  scarlet  fever,  cerebrospinal  fever,  diphtheria,  and  typhoid 
fever.  In  some  cases  influenza  may  act  as  a  cause.  Any  of  the  septic 
conditions  are  also  liable  to  provoke  inflammation  in  the  endocardium. 

Pathology. — In  fetal  life  the  right  side  of  the  heart  is  attacked, 
but  this  rarely  occurs  after  birth  when  the  left  side  is  almost  exclusively 
affected.  The  valves  are  most  frequently  the  seat  of  the  inflammation, 
25 


386  DISEASES  OF  CHILDREN. 

the  mitral  valve  being  oftenest  affected  and  next  the  aortic,  and  occa- 
sionally the  pulmonary  valves.  The  affected  valve  is  thickened  from 
a  proliferation  of  connective-tissue  cells  and  may  be  covered  by  small 
deposits  of  fibrin,  especially  around  the  margins.  Small  thrombi 
and  vegetations  may  also  be  present,  which  are  liable  to  separate  and 
be  carried  into  the  general  circulation.  In  this  manner  secondary 
infections  are  liable  to  take  place  in  various  vital  organs.  Leakage 
of  the  valve  may  be  caused  by  contractions  of  the  chordae  tendinae  or 
ulceration  with  perforation  of  the  valve.  Streptococci  or  the  staphylo- 
coccus pyogenes  are  the  bacteria  that  most  frequently  infect  and  inflame 
the  endocardium  and  rarely  pneumococci,  either  from  the  presence 
of  the  bacteria  or  their  toxins  in  the  blood  stream.  The  tonsils  have 
been  supposed  to  be  the  primary  seat  of  many  of  the  bacteria  that 
thus  affect  the  heart,  and  cases  have  been  reported  of  endocarditis 
following  tonsillitis.  There  is  usually  some  inflammation  of  the  myo- 
cardium coexisting  with  endocarditis  which  causes  a  softening  of 
the  heart  muscle  and  consequent  dilatation.  This  may  account 
for  some  of  the  valvular  insufficiency  seen  during  and  after  the  attack. 

Symptomatology. — The  symptoms  are  often  very  obscure, 
being  masked  by  the  original  infectious  disease  that  is  the  cause  of  the 
heart  lesion.  On  this  account  the  heart  must  be  frequently  and  care- 
fully examined  during  attacks  of  rheumatism,  scarlet  fever,  diphtheria, 
and  in  any  septic  condition.  A  soft,  systolic  murmur  is  usually  heard, 
most  noticeable  at  the  apex  and  transmitted  toward  the  axillary  region. 
There  may  be  slight  dyspnea  and  evidences  of  some  dilatation,  espe- 
cially if  the  child  cannot  be  kept  quiet.  An  irregular  fever  with  in- 
creased respiration  and  pulse  rate  may  also  be  noted.  Young  children 
rarely  complain  of  pain  or  discomfort  in  the  cardiac  region  but 
older  children  may  describe  a  feeling  of  constriction,  slight  pain,  or 
palpitation. 

Septic  Endocarditis. — The  symptoms  of  this  form  of  endocarditis, 
otherwise  known  as  malignant  or  ulcerative  endocarditis,  are  much 
more  urgent  and  marked.  There  are  chills  with  high,  irregular  fever 
and  sweats.  There  is  likewise  great  prostration,  with  delirium  and 
even  coma.  There  are  no  characteristic  symptoms  referable  to  the 
heart  beside  a  murmur  and  possibly  more  marked  dyspnea  than  in  the 
ordinary  attacks.  Ulcerations  take  place  on  the  valves,  and  septic  em- 
boli are  liable  to  be  detached  and  carried  to  the  lungs,  kidneys,  brajn, 
or  other  vital  organs.  A  typical  sign  consists  of  purpuric  spots  or 
petechiae  which  soon  appear  on  the  neck,  chest,  abdomen,  or  extremi- 
ties. This  form  of  endocarditis  may  occur  in  any  septic  condition, 
when  various  bacteria  may  be  found  in  the  blood  and  thus  the  cause 


DISEASES  OF  THE  HEART.  387 

of  the  heart  lesion  demonstrated.  Fortunately,  septic  or  malignant 
endocarditis  is  very  rare  in  early  life  and  it  is  a  fatal  disease. 

Diagnosis. — A  soft,  systolic  murmur  at  the  apex  that  develops 
during  an  illness,  with  irregularity  of  the  heart's  action  and  some 
dilatation  is  suspicious  of  endocarditis.  The  murmur  is  transmitted 
toward  the  axilla  and  is  usually  accompanied  by  fever  and  increased 
rapidity  of  the  pulse.  A  purring  thrill  may  also  be  present  and  an 
increased  pulsation  over  the  area  of  the  heart's  action.  Hemic  or 
myocardial  murmurs  are  inconstant,  are  noted  especially  at  the  base 
or  over  the  pulmonic  area  and  are  not  transmitted.  These  murmurs 
are  usually  systolic,  but  there  is  no  evidnece  of  dilatation  or  marked 
cardiac  disturbance  and  there  is  absence  of  fever  and  other  signs  of 
acute  illness.  Pericarditis  is  recognized  by  the  friction  sound,  or 
dullness  on  percussion,  or  absence  of  distinct  apex  beat  when  effusion 
is  present. 

Prognosis. — The  prognosis  is  good  as  regards  life,  except  in  the 
septic  or  ulcerative  form.  The  outlook  is  not  so  good  with  reference 
to  the  future  ciippling  of  the  heart  from  thickening  or  retraction  of  the 
valves.  Cases  have  been  reported,  however,  in  which  no  permanent 
lesion  has  followed  endocarditis,  especially  when  the  disease  has  been 
early  recognized  and  the  child  kept  quiet.  Most  of  the  cases,  espe- 
cially those  of  rheumatic  origin,  are  followed  by  some  permanent  lesion. 

Treatment. — Rest  in  bed  in  a  recumbent  position  is  very  impor- 
tant during  the  acute  stage.  Any  exertion  that  results  in  dilatation 
of  the  softened  heart  muscle  will  cause  valvular  insufficiency.  An 
ice-bag  may  be  placed  over  the  heart  in  cases  of  severe  palpitation. 
Tumultuous  heart  action  may  also  be  controlled  by  aconite  or  by 
small,  non-narcotic  doses  of  opium.  The  latter  drug  will  also  tend 
to  allay  restlessness  and  thus  render  it  easier  to  keep  the  child  quiet. 
Grains  -V  to  ^V  of  morphin  sulphate  may  thus  do  good  service.  If  the 
heart's  action  is  weak,  with  evidences  of  dilatation,  strychnia  or 
digitalis  will  be  indicated.  Where  rheumatism  is  present,  it  may  be 
treated  by  sodium  salicylate,  aspirin,  or  alkalies.  The  bowels  must  be 
kept  open,  and  a  light,  fluid  diet  given.  In  cases  having  a  weak  or 
dilated  heart  with  irregular  pulse,  it  may  be  necessary  to  keep  the  child 
quiet  in  bed  for  some  weeks  or  until  a  distinct  improvement  is  noted. 

In  septic  endocarditis  blood  cultures  should  be  made  twice  a 
week  in  the  effort  of  finding  the  organism.  (This  requires  expert  and 
specialized  laboratory  technic.)  When  the  organism  is  found  a 
homologous  vaccine  can  be  made  and  used  according  to  Wright's 
method.  Recent  reports  (Thompson,  etc.)  have  been  extremely  en- 
couraging in  this  heretofore  fatal  disease. 


388  DISEASES  OF  CHILDREN. 

Myocarditis. 

Myocarditis  is  an  inflammation  of  the  heart  muscle  followed  by 
softening  and  degeneration. 

Etiology. — The  toxins  produced  by  the  bacteria  of  the  various 
infectious  diseases  may  cause  an  inflammation  of  the  heart  muscle. 
Diphtheria  and  scarlet  fever  are  the  diseases  most  often  responsible 
for  thus  attacking  the  heart. 

Pathology. — In  some  cases  there  is  a  cloudy  sweUing  and  a  granu- 
lar and  hyalin  degeneration  of  the  muscle  fibers,  and  in  others  there 
will  be  a  fatty  degeneration.  If  the  latter  is  extensive,  a  cut  section 
will  show  a  yellowish  appearance  of  the  heart  muscle.  There  may 
also  be  a  small,  round-celled  infiltration  between  the  muscular  fibers. 

Symptomatology. — The  milder  forms  of  the  disease  may  show  no 
symptoms  referable  to  the  heart.  In  severer  attacks  there  will  be 
dyspnea,  faint  feelings,  and  a  rapid,  irregular  pulse.  It  is  difficult  to 
locate  the  position  of  the  apex  beat,  and  there  will  be  an  increased  area 
of  cardiac  dullness  due  to  dilatation.  The  grave  cases  show  general 
pallor  with  cyanosis  of  the  lips  and  finger-tips,  and  a  sudden  collapse 
from  heart  failure  may  be  the  terminal  condition.  The  symptoms 
are  liable  to  be  masked,  as  in  endocarditis,  by  the  primary  infectious 
disease.  Vomiting,  occurring  in  connection  with  a  weak,  irregular 
pulse  in  diphtheria,  is  usually  of  serious  import.  A  pulse  becoming 
slow  in  an  infectious  disease,  especially  diphtheria,  after  having  been 
rapid  is  of  grave  significance.  We  have  seen  the  pulse  drop  from  150 
to  50  and  40,  and,  in  one  case  it  reached  25  in  diphtheria  wdth  a  com- 
plicating myocarditis.  Death  nearly  always  ensues  in  cases  having  a 
very  slow  pulse.  In  chronic  and  severe  valvular  disease,  a  lack  of  tone 
in  the  heart  muscle  due  to  a  slow  and  progressive  myocarditis  will  be 
shown  by  failure  of  compensation  with  resulting  dyspnea,  congestion 
and  enlargement  of  the  viscera,  and  dropsies. 

Diagnosis. — The  diagnosis  rests  upon  a  weak  and  irregular  action 
of  the  heart,  a  feeble  first  sound,  and  accentuation  of  the  pulmonic 
second  sound  and  difficulty  in  locating  the  apex  beat.  In  addi- 
tion to  these  local  signs  there  will  be  faintness,  pallor,  and  general 
prostration. 

Treatment. — The  heart  must  be  supported  by  absolute  rest  in  the 
recumbent  position.  Sudden  dilatation  and  weakness  may  be  com- 
bated by  hypodermatic  injections  of  small  doses  of  morphin  and  atro- 
pin.  Sulphate  of  strychnin  is  useful  in  sustaining  the  heart's  action. 
Prolonged  rest  and  avoidance  of  exertion  must  be  insisted  upon  during 
convalescence. 


CHAPTER  XXVIII. 
CHRONIC  VALVULAR  DISEASE. 

Physicians  are  often  called  upon  to  treat  cases  with  valvular  dis- 
eases of  the  heart  when  it  is  impossible  to  find  out  the  beginning  of  the 
trouble.  The  patient  may  be  unable  to  give  a  history  either  of 
rheumatism  or  endocarditis,  but  seeks  advice  for  dyspnea,  swelling 
of  the  extremities,  or  other  symptoms  of  failing  circulation.  We 
believe  that  a  large  proportion  of  the  cases  of  valvular  disease  in  the 
adult  have  started  during  childhood.  The  first  beginning  of  the 
trouble,  which  is  the  period  for  hopeful  treatment,  is  not  recognized. 
The  nature  of  the  rheumatism  that  attacks  children  is  often  obscure, 
and  several  attacks  of  wandering  or  so-called  "growing  pains"  may  be 
overlooked.  While  the  heart  may  be  the  first  structure  attacked  by 
rheumatism,  this  is  not  the  common  order  of  events.  In  most  of 
our  histories  of  valvular  disease  in  children,  the  cardiac  affection 
seemed  to  come  on  after  several  attacks  of  rheumatism.  Great  care 
should  be  exercised  in  making  an  early  diagnosis,  and  vigorous  meas- 
ures be  taken  to  combat  these  first  manifestations  of  rheumatism, 
fearful  that,  although  the  heart  may  escape  the  first  mild  attacks, 
it  may  suddenly  and  unexpectedly  become  affected  by  an  equally 
light  manifestation  of  the  disease. 

When  endocarditis  ensues,  as  previously  noted,  the  symptoms  are 
often  very  obscure.  Palpitation,  slight  pain,  and  breathlessness,  with 
a  dry  cough,  may  not  be  particularly  noticed  by  parents.  In  all 
suspicious  cases  we  would  strongly  emphasize  the  importance  of  a 
careful  examination  of  the  heart  on  the  part  of  the  physician,  a 
stethoscope  being  used.  Just  at  this  juncture  rest  is  indicated  above 
all  things.  If  this  is  not  procured,  the  delicate,  softened  heart  muscle 
quickly  undergoes  dilatation,  followed  by  permanent  damage  to  the 
valve.  Dilatation  takes  place  very  readily  in  the  young  subject.  If 
it  is  true  that  endocarditis  need  not  always  nor  necessarily  eventuate 
in  permanent  valvular  disease,  and  this  seems  to  be  generally  believed, 
we  may  certainly  aid  such  a  result  by  doing  all  in  our  power  to  avoid 
dilatation.  By  recognizing  the  endocarditis  at  the  beginning  and 
keeping  the  child  as  quiet  as  possible,  we  may  thus  seek  to  avoid 
dilatation  and  consequent  crippling  of  the  valves.     Even  after  the 

389 


390  DISEASES  OF  CHILDREN. 

immediate  symptoms  of  endocarditis  have  passed,  children  are  too 
often  allowed  to  take  part  in  all  kinds  of  vigorous  exercises  as  if 
nothing  amiss  had  happened. 

In  many  cases  children  suffering  from  chronic  valvular  disease 
show  few  symptoms  of  circulatory  disturbance.  This  is  explained 
by  a  more  or  less  perfect  compensation  which  generally  and  completely 
ensues  from  hypertrophy,  and  there  may  thus  be  no  positive  sign 
until  years  later  that  serious  damage  has  been  effected.  The  periph- 
eral arteries  are  also  healthy  and  elastic  at  this  time,  which  fact,  as  pre- 
viously noted,  greatly  facilitates  the  work  of  the  heart.  As  the  patients 
grow  older,  and  vascular  degenerations  begin,  and  the  limit  of  com- 
pensatory hypertrophy  is  reached,  marked  dyspnea  and  other  symp- 
toms of  a  failing  circulation  will  be  noted.  We  have  seen  children 
after  a  severe,  neglected  case  of  endocarditis,  or  after  several  attacks, 
suffer  in  this  way,  but  in  a  large  number  of  cases  the  principal  evidence 
of  valvular  disease  will  be  shown  by  general  underdevelopment,  mal- 
nutrition, and  anemia. 

The  extent  of  the  heart  lesion  cannot  be  estimated  by  the  rela- 
tive loudness  or  softness  of  the  murmur.  We  must  estimate  the 
amount  of  crippling  caused  by  valvular  defect  by  two  factors  in  our 
examination  of  the  heart:  first,  the  position  of  the  apex  beat,  and  second 
a  marked  accentuation  of  the  pulmonic  second  sound.  If  there  is  no 
hypertrophy  of  any  part  of  the  heart  muscle,  it  is  not  probable  that 
any  real  valvular  defect  is  present.  While  in  early  life  the  pulmonic 
second  sound  is  relatively  louder  than  in  later  years,  if  it  is  very 
markedly  accentuated,  there  is  evidently  an  interference  to  the  pas- 
sage of  the  blood  through  the  lungs  due  to  some  valvular  lesion. 

In  early  years,  the  mitral  valve  alone  is  most  frequently  the  seat 
of  chronic  disease;  next  a  combination  of  mitral  and  aortic  lesions  is 
found,  and  very  rarely  the  aortic  valve  alone  is  affected.  This  is  ex- 
plained by  the  fact  that  the  mitral  valve  is  most  often  attacked  by 
rheumatism,  while  atheroma,  gout,  and  old  age  are  the  commonest 
causes  of  aortic  disease. 

Location  of  the  Valves. —  The  mitral  valve  is  situated  at  a  point 
where  the  upper  border  of  the  left  fourth  costal  cartilage  joins  the  left 
border  of  the  sternum.  The  aortic  valves  are  placed  behind  the  ster- 
num at  the  junction  of  its  left  margin  with  the  lower  edge  of  the  third 
left  costal  cartilage.  The  pulmonary  valves  are  located  at  the  junction 
of  the  left  border  of  the  sternum  and  the  third  left  costal  cartilage. 
The  tricuspid  valves  are  found  behind  the  middle  of  the  sternum  on 
the  level  of  the  line  connecting  the  fourth  costosternal  cartilages. 
The  valves  of  the  left  heart  are  situated  deeper  than,  and  behind  those 


CHRONIC  VALVULAR  DISEASE.  391 

of  the  right  heart.  Organic  defects  in  the  valves  give  rise  to  adven- 
titious sounds  known  as  organic  cardiac  murmurs,  produced  by  the 
passage  of  the  blood  over  or  through  the  valves  afifected.  These  mur- 
murs are  not  heard  with  maximum  intensity  directly  over  the  valve 
affected,  but  near  it,  and  are  transmitted  in  the  direction  of  the  blood 
current.  The  following  are  the  locations  of  the  loudest  «ounds  in  the 
valves  when  diseased:  mitral  murmurs  loudest  at  the  apex;  aortic 
murmurs  loudest  at  second  right  intercostal  space;  tricuspid  murmurs 
loudest  at  the  ensiform  cartilage. 

Mitral  Regurgitation. 

Any  insufficiency  or  leak  in  the  mitral  valves  will  be  followed  by 
regurgitation  of  blood  during  the  systole.  There  will  then  ensue,  first, 
a  dilatation  and  hypertrophy  of  the  left  auricle;  next,  hypertrophy  of 
the  left  ventricle  required  by  the  extra  work  thrown  upon  it  in  propel- 
ling the  blood  through  the  aortic  valves,  and,  finally,  an  hypertrophy 
of  the  right  ventricle  which  has  difficulty  in  forcing  the  blood  through 
the  lungs  to  be  emptied  in  the  left  auricle. 

A  phj^sical  examination  will  show  general  evidence  of  enlargement. 
A  visible  impulse  of  the  heart's  action  can  usually  be  detected  and  the 
apex  beat  is  felt  below  and  to  the  left,  or  outside  its  usual  location. 
On  percussion,  the  area  of  dullness  will  be  increased  to  the  left  and 
below^  from  enlargement  of  the  left  auricle  and  ventricle.  On  auscul- 
tation a  systolic  murmur  is  heard,  having  a  blowing  and  rarely  a 
musical  character.  The  murmur  is  transmitted  from  the  apex  across 
the  axilla  to  the  inferior  angle  of  the  left  scapula.  The  murmur  is 
sometimes  heard  in  children  at  the  latter  location  behind,  plainer  than 
at  the  apex  at  front.  An  accentuation  of  the  pulmonic  second  sound 
is  usually  marked. 

Mitral  Obstruction. 

A  presystolic  or  auriculoventricular  sound  is  produced  by  some 
interference  with  the  normal  and  easy  passage  of  blood  through  the 
auriculoventricular  septum  or  valve.  The  murmur  is  rough  and 
blubbering  in  quality,  beginning  at  the  end  of  diastole  and  ending  ab- 
ruptly with  systole.  One  of  the  most  characteristic  points  about  this 
murmur  is  its  abrupt  termination.  This  quick  stop  of  the  abnormal 
bruit  is  very  different  from  the  gradual  ending  of  mitral  regurgitation. 
The  obstruction  in  the  valve  leads  to  hypertrophy  of  the  left  auricle  and 
finally  to  enlargement  of  the  right  ventricle  which  has  more  work  to  do 
in  flushing  the  blood  through  the  lungs.     The   left  ventricle   is  not 


392  DISEASES  OF  CHILDREN. 

hypertrophied,  and  accordingly  the  apex  beat  will  appear  in  about  its 
normal  location.  Any  enlargement  will  be  noted  by  an  increased  area 
of  dullness  to  the  right  of  the  sternum.  A  purring  thrill  is  usually 
felt  by  placing  the  hand  over  the  heart.  On  auscultation  a  blubber- 
ing murmur  is  heard  only  in  the  region  of  the  apex  and  is  not  trans- 
mitted. It  is  likewise  somewhat  variable  and  may  be  hardly  audible 
during  repose  and  yet  very  evident  when  the  patient  is  required 
to  make  some  exertion.  The  pulmonic  second  sound  is  always 
accentuated. 

Chapin  has  reported  a  series  of  forty  cases  in  which  children 
giving  evidence  of  mitral  obstruction  were  kept  under  observation 
for  different  intervals  of  time  from  a  few  weeks  to  several  years.  The 
commonest  symptoms  noted  were  varying  degrees  of  pain  referred  to 
the  region  of  the  heart  and  dyspnea  on  exertion.  Thirty-one  of  the 
cases  gave  evidence  of  simple  mitral  obstruction,  while  in  nine  cases 
there  were  combined  murmurs.  Most  of  the  cases  were  preceded  by 
a  rheumatic  manifestation  that  was  mild  even  for  children,  and  he 
concludes  that  while  mitral  stenosis  is  not  independent  of  rheumatism 
it  is  apt  to  be  associated  with  the  less  pronounced  forms  of  it. 

In  growing  children,  especially  girls,  who  are  pale,  nervous, 
anemic,  and  troubled  with  digestive  disturbance,  an  irregular  action  of 
the  heart  may  produce  a  rough  sound  simulating  mitral  obstruction, 
which  disappears  under  improved  conditions. 

Aortic  Obstruction. 

This  lesion  is  infrequent  in  childhood.  It  is  accompanied  by  a 
systolic  murmur  heard  at  the  base  at  the  second  right  interspace  and 
transmitted  upward.  The  aortic  second  sound  is  somewhat  weakened, 
but  there  is  no  accentuation  of  the  pulmonic  second  sound.  There  is 
hypertrophy  of  the  left  ventricle  and  the  apex  beat  is  accordingly 
pushed  downward  and  outward.  The  latter  will  distinguish  this  sound 
from  functional  or  hemic  murmurs  with  which  it  is  apt  to  be  confused. 

Aortic   Regurgitation. 

This  lesion  is  likewise  not  very  frequently  seen  in  early  life. 
The  murmur  is  diastolic,  taking  the  place  of  the  aortic  second  sound. 
It  is  rather  harsh  in  character  and  is  transmitted  downward  over  the 
sternum,  being  heard  with  greatest  intensity  at  about  the  fourth 
cartilage  or  sometimes  at  the  lower  extremity  of  the  sternum.  There 
is  great  hypertrophy  of  the  left  ventricle,  and  accordingly  much  dis- 
placement of  the  apex  beat  downward  and  outward,  and  the  heart 


CHRONIC  VALVULAR  DISEASE.  393 

usually  acts  with  considerable  force.  The  so-called  "water-hammer 
pulse"  is  typical,  consisting  of  a  full,  arterial  wave  followed  by  a 
sudden  fall  in  the  pressure. 

Tricuspid  Regurgitation. 

This  lesion  is  very  rare  and  apt  to  be  overlooked.  It  may  be 
caused  by  disease  of  the  valve  itself  or  secondary  to  a  dilated  right 
ventricle.  There  is  a  very  soft  systolic  murmur  heard  over  the 
ensiform  cartilage.  It  is  distinguished  from  aortic  regurgitation  by 
being  systolic  instead  of  diastolic,  and  also  by  more  marked  cyanosis, 
by  pulmonary  edema,  and  jugular  pulsation. 

Prognosis  in  Valvular  Disease. — The  immediate  prognosis  in 
children,  even  when  the  lesion  is  fairly  severe  and  extensive,  is  usually 
good  for  reasons  already  noted.  There  is  nearly  always,  however,  a 
more  or  less  defective  nutrition.  There  are  cases  in  which  slight 
lesions  appear  to  undergo  complete  recovery,  especially  when  a 
healthy  general  growth  can  be  accomplished.  Repeated  attacks  of 
rheumatism,  with  the  danger  of  renewed  endocarditis,  are  a  grave 
menace  to  the  heart  by  upsetting  compensation  and  increasing  existing 
lesions  or  forming  others.  The  ultimate  prognosis  is  not  good  in 
most  cases  of  marked  valvular  disease,  as  it  is  only  a  question  of  time 
when  the  compensation  will  fail  in  later  life. 

Treatment. — Many  cases  require  no  treatment  directed  to  the 
heart,  but  the  general  nutrition  and  growth  require  careful  oversight. 
Nourishing,  digestible  food,  with  the  occasional  administration  of 
remedies  to  build  up  tissues,  such  as  iron  and  cod-liver  oil,  are  fre- 
quently all  that  are  required.  These  cases  should  not  be  restricted  too 
much  in  exercise  and  amusement.  All  the  milder  games  may  be 
allowed,  only  avoiding  the  more  violent  and  competitive  sports.  Any 
acute  infectious  disease  and  the  slightest  manifestation  of  rheumatism 
must  mean  extra  rest,  and  anxious  care  on  the  part  of  the  physician. 
Any  evidence  of  failing  compensation  will  likewise  require  rest  and  the 
administration  of  heart  tonics,  especially  strychnin  and  digitalis. 
In  cases  of  great  dyspnea  and  restlessness  small  doses  of  codein  by  the 
mouth  or  minute  non-narcotic  doses  of  morphin  given  hypoder- 
matically  will  often  afford  relief. 

Functional  Cardiac  Disorders. 

The  heart  in  growing  children,  especially  those  with  a  neurotic 
tendency,  is  very  prone  to  functional  disorder.  Digestive  disturbances 
and  the  anemias  are  the  commonest  exciting  causes. 


394  DISEASES  OF  CHILDREN. 

Palpitation  of  the  heart. — This  is  seen  in  connection  with  dyspepsia 
from  the  use  of  improper  food  or  from  the  abuse  of  tea,  coffee,  or  con- 
diments. In  older  children  the  strain  from  overstudy  or  from  mastur- 
bation, especially  at  the  time  of  adolescence,  is  a  common  cause. 
The  heart  may  be  unusually  slow  or  rapid  in  action,  but  oftener  the 
latter. 

Hemic  Murmurs. — These  murmurs  are  not  often  heard  in  infants 
and  very  young  children,  but  are  fairly  frequent  in  older  children. 
They  are  invariably  systolic  and  are  usually  heard  at  the  base.  A 
diastolic  murmur  is  always  organic.  The  hemic  murmurs  are  heard 
more  distinctly  over  the  pulmonary  than  over  the  aortic  interspace, 
are  inconstant,  and  are  not  transmitted  in  the  direction  of  the  blood 
current.  They  are  usually  accompanied  by  a  venous  hum  in  the 
jugular  and  subclavian  veins.  The  most  reliable  differentiation 
between  hemic  and  organic  murmurs  consists  in  the  enlargement  of 
the  heart  from  compensatory  hypertrophy  seen  in  the  latter.  Mur- 
murs, apparently  of  hemic  origin,  are  sometimes  noted  in  acute  febrile 
affections.  Dynamic  murmurs,  due  to  a  faulty  action  of  the  heart 
muscle,  are  sometimes  detected  after  violent  exercise  and  in  choreic  or 
hysterical  children.  A  cardiorespiratory  murmur  may  be  produced 
by  the  impulse  of  the  heart  against  some  of  the  pulmonary  vesicles 
at  the  end  of  a  deep  inspiration.  It  is  always  systolic  and  is  not  heard 
at  the  end  of  expiration. 

Treatment. — The  management  of  functional  heart  troubles  is, 
principally  dietetic  and  hygienic.  The  digestion  must  be  carefully 
regulated  and  only  nourishing  and  easily  assimilable  food  be  allowed. 
It  may  be  necessary  to  remove  the  children  from  school  so  that  they 
can  be  free  from  nervous  strain  and  have  more  opportunity  to  get 
plenty  of  fresh  air  and  sunlight.  All  the  known  sources  of  nervousness 
must  be  removed  and  opportunity  given  for  abundance  of  sleep. 
Iron  and  cod-liver  oil  are  the  best  remedies.  Small  doses  of  Fowler's 
solution  may  also  be  employed. 


CHAPTER  XXIX. 
DISEASES  OF  THE  PERICARDIUM. 

Pericarditis. 

This  is  an  inflammation  of  the  pericardium  secondary  to  rheu- 
matism or  some  infectious  disease. 

Etiology. — The  most  frequent  cause  is  acute  articular  rheu- 
matism. It  may  also  occur  in  connection  with  the  exanthemata, 
especially  scarlet  fever,  in  various  septic  processes,  in  tuberculosis 
and  pneumonia.  Direct  injury  is  rarely  a  cause,  and  it  may  spread 
by  continuity  from  pleurisy.  The  following  bacteria  may  act  as 
exciting  causes — streptococci,  staphylococci,  the  tubercle  bacillus, 
the  colon  bacillus  and  the  pneumococcus. 

Pathology. — We  may  recognize  three  varieties — the  fibrinous, 
serofibrinous  and  purulent,  according  to  the  inflammatory  exudate. 
In  the  first  or  adhesive  form,  the  pericardium  is  covered  by  an  exuda- 
tion of  fibroplastic  matter  which  may  lead  to  adhesions  between  the 
visceral  and  parietal  surfaces.  In  the  serofibrinous  form,  the  peri- 
cardial sac  contains  a  serous  fluid,  together  with  a  fibrinous  exudation, 
which  produces  adhesions  on  absorption  of  the  fluid.  The  sero- 
fibrinous exudation  may  occasionally  become  purulent,  and  rarely 
blood  is  exuded  into  the  sac.  Miliary  tubercles  may  infiltrate  both 
the  visceral  and  parietal  surfaces  in  the  tuberculous  form.  Permanent 
adhesions  will  be  produced  by  the  fibrinous  exudation  being  replaced 
by  new  connective  tissue.  More  or  less  myocarditis  is  present  in 
connection  with  pericarditis,  the  same  as  in  endocarditis. 

Symptomatology. — The  symptoms  are  of  such  a  negative  character 
that  the  disease  is  often  overlooked.  As  it  is  usually  a  secondary 
condition,  the  original  disease  is  apt  to  mask  the  symptoms  that  are 
present  and  occupy  all  the  attention  of  the  physician.  Palpitation 
of  the  heart,  dyspnea,  more  or  less  pain  in  the  epigastric  region,  rapid, 
irregular  pulse,  and  increased  respirations  are  usually  present.  In 
severe  cases  cyanosis  may  be  marked.  Where  pus  is  present  in  the 
effusion,  the  temperature  assumes  a  more  remittent  curve. 

Physical  Signs. — As  the  rational  signs  are  obscure,  the  physical 
signs  assume  great  importance  in  making  a  diagnosis.  In  the  fibrous 
form,  a  superficial  friction  sound,  synchronous  with  the  beat  of  the, 

395 


396  DISEASES  OF  CHILDREN. 

heart  may  be  detected.  It  may  be  heard  on  systole  alone,  or  with 
both  systole  and  diastole.  It  is  usually  more  distinct  at  the  base,  but 
it  may  also  be  heard  toward  the  apex,  especially  at  the  onset  of  the 
disease,  and  is  not  transmitted.  At  first,  tthe  sound  may  have  a 
crepitant  quality,  but  later  assumes  a  coarser,  rubbing,  or  rasping 
character.  A  friction  fremitus  may  be  felt  over  the  region  in  which 
the  friction  rub  is  localized  by  auscultation. 

In  the  serous  form  there  may  be  some  bulging  at  the  precordial 
region,  depending  upon  the  amount  of  the  effusion.  From  one  to 
two  fluidounces  must  be  present  in  the  pericardial  sac  in  order  to  pro- 
duce marked  signs.  The  apex  beat  is  not  distinct,  being  pushed  up- 
ward and  to  the  left.  Where  there  is  extensive  effusion,  the  apex  beat 
may  be  lost.  There  will  be  an  increased  area  of  precordial  dullness 
over  the  distended  sac.  It  may  extend  on  the  left  outside  the  mam- 
mary line  from  the  seventh  rib  up  to  the  first  rib,  and  from  a  little  to 
the  right  of  the  sternum  down  to  the  liver.  As  in  plueral  effusions, 
there  will  be  a  slight  resistance  to  the  finger  on  percussing.  On  aus- 
cultation the  heart  sounds  are  muffled  or  feebly  heard,  and  the  apex 
is  located  with  difficulty,  if  at  all.  As  the  fluid  is  absorbed  the  friction 
rub  will  again  be  noted  and  the  valvular  sounds  become  more  distinct. 

Diagnosis. — This  must  be  made  by  a  careful  examination  of  the 
heart  in  reference  to  the  physical  signs  just  noted.  In  endocarditis  the 
apex  can  be  located  and  the  soft,  blowing  murmur  is  transmitted. 
Acute  dilatation  of  the  heart  and  hypertrophy  will  show  an  enlarge- 
ment and  increased  area  of  dullness,  but  there  will  be  no  friction 
rub  nor  signs  of  effusion,  and  the  previous  history  will  help  to  throw 
light  on  the  case.  A  left  pleural  effusion,  with  or  without  pericardial 
effusion,  may  raise  a  difficult  point  in  diagnosis.  The  flatness  from 
the  pleural  effusion  will  not  extend  over  the  heart  and  sternum  if 
there  is  no  pericardial  effusion,  but,  if  both  are  present,  the  extensive 
dullness  and  feeble  or  absent  heart  sounds  will  afford  a  probable 
diagnosis. 

Prognosis. — The  immediate  outlook  is  good  except  in  the  septic 
and  purulent  forms  of  the  disease.  The  heart  may,  however,  be  per- 
manently crippled  in  the  case  of  extensive  adhesions. 

Treatment. — The  child  must  be  kept  perfectly  quiet  in  the  recum- 
bent position  as  in  all  other  forms  of  acute  heart  trouble,  and  milk  or 
other  bland  food  given.  Tumultuous  action  may  be  controlled  by  an 
ice-bag  over  the  heart.  Small  doses  of  morphin  or  codein  may  be 
employed  to  quiet  and  strengthen  the  heart's  action,  to  control  pain, 
and  relieve  restlessness.  If  the  heart  is  weak  and  unsteady,  strychnia, 
digitalis,  or  alcohol  may  be  employed.     Where  effusion  is  extensive 


DISEASES  OF  THE  PERICARDIUM.  397 

enough  to  seriously  embarrass  the  action  of  the  heart,  aspiration 
has  been  tried,  but  with  doubtful  results.  We  have  seen  a  case  of 
sudden  death  due  to  a  slight  puncture  of  the  heart  muscle  where 
this  operation  was  employed.  Rheumatism  if  present,  or  the  original 
causative  disease,  must  be  treated  in  connection  with  the  measures 
aimed  at  the  pericarditis. 


SECTION  IX. 

DISEASES  OF  THE  BLOOD  AND  DUCTLESS 

GLANDS. 


CHAPTER   XXX. 
DISEASES  OF  THE  BLOOD. 
Glossary. 

Corpuscular  Elements. 

Erythrocytes red  cells. 

Leukocytes white  cells. 

Poikilocytosis variations  in  shape  of  red  cells. 

Normoblast nucleated  red  cell  of  normal  size. 

Microblast nucleated  red  cell  of  small  size. 

Megaloblast nucleated  red  cell  of  large  size. 

Leukocytosis   (or  hyperleukocytosis) :     increase  in  total  number  of 
white  cells  (more  than  12,000)  usually  implies  a  polynucleosis. 
Leukopenia:  decrease  in  total  number  of  white  cells  (below  6,000). 
Polynucleosis:  relative  and  absolute  increase  of  the  polynuclears. 
Lymphocytosis  :  relative  and  absolute  increase  in  lymphocytes. 
Eosinophilia  :  relative  and  absolute  increase  in  eosinophiles. 

Blood. 

Blood  consists  of  a  clear  yellowish  fluid,  the  plasma,  in  which 
float  the  cellular  elements  or  corpuscles,  the  red  cells  giving  to  blood 
its  characteristic  color;  the  white  cells  or  leukocytes  act  as  phagocytes, 
and  the  blood  plates  are  the  product  of  degenerating  leukocytes. 

Normal  blood  contains  the  following  number  of  cells  and  blood- 
plates  to  the  cubic  millimeter. 

Erythrocytes 4,500,000  to  5,000,000 

Leukocytes 7,500 

Plates 150,000  to  300,000 

The  color  of  blood  is  due  to  the  presence  of  hemoglobin,  an 
organic  compound  of  iron.  When  of  normal  intensity,  this  color  is 
given  as  100  per  cent.  The  color-index  of  a  specimen  of  blood  is 
obtained  by  dividing  the  per  cent,  of  hemoglobin  by  the  per  cent,  of 
red  blood-cells.     Normally,  the  color-index  is  loo  per  cent:  ^^- 

The  specific  gravity  of  blood  is  highest  in  the  new-born  and  during 
the  first  week  or  two  falls  to  its  lowest  point.  It  remains  low  during 
the  first  two  years  of  life,  averaging  1.050  to  L055,  then  gradually 

398 


»  DISEASES  OF  THE  BLOOD.  399 

increases  as  puberty  is  reached.  In  adults  the  specific  gravity  is 
about  1.059.  The  specific  gravity  varies  directly  with  the  amount  of 
hemoglobin  present. 

Red  blood-cells  (erythrocytes)  are  most  numerous  per  cubic 
millimeter  in  the  first  twenty-four  hours  of  life,  Hayem  estimating 
the  number  to  be  5,900,000.  This  number  gradually  falls  during  the 
days  in  which  the  infant  loses  weight.  About  the  seventh  day  the 
average  number  per  cubic  millimeter  is  4,500,000.  This  is  the  average 
number  of  cells  throughout  childhood.  Hayem  is  also  the  authority  for 
the  statement  that  early  ligation  of  the  funis  reduces  the  number 
of  red  blood-corpuscles  about  500,000  per  cubic  millimeter. 

Trifling  causes  in  infancy  and  childhood  result  in  marked  changes 
in  the  red  blood-corpuscles  in  number,  size,  and  shape;  hence  poikilo- 
cytosis  and  anemia  are  common. 

The  red  blood-cell  is  a  biconcave  disk,  non-nucleated,  varying 
greatly  in  diameter,  3.3  micromillimeters  to  10.3  micromillimeters 
having  opaque  yellowish  rims  and  nearly  transparent  centers.  In 
adults  they  show  a  marked  tendency  to  cohere  by  their  flat  surfaces 
forming  long  rows  (rouleaux),  though  in  infancy  this  property  is  much 
less  marked. 

Nucleated  red  cells  are  not  normally  found  in  infants.  In 
prematures  they  may  be  found  for  three  or  four  days.  There  are 
three  varieties  of  nucleated  red  cells:  (1)  Normoblast  which  re- 
sembles a  normal  red  cell  in  all  particulars  except  that  it  is  nucleated; 
(2)  Megaloblast — a  large  cell  10  micromillimeters  to  20  micro- 
millimeters in  diameter— seen  only  in  severe  anemias;  (3)  Microcyte 
which  is  smaller  than  the  ordinary  red  cell;  this  form  is  rare. 

White  blood-corpuscles  (or  leukocytes)  vary  in  size  from  the 
size  of  a  red  cell  to  two  or  three  times  that  size.  In  the  fresh  state 
the  larger  ones  present  ameboid  movements  if  kept  at  body  tempera- 
ture. In  stained  specimens  the  following  forms  may  be  recognized. 
(1)  Polynuclears  (or  polymorphonuclear  neutrophilic  leukocytes); 
these  constitute  about  two-thirds  of  all  the  white  corpuscles  in  normal 
adult  blood.  In  infancy,  they  occur  in  about  18  to  40  per  cent. 
Stained  by  Wright's  method,  the  nucleus  takes  on  a  deep  navy-blue 
color.  The  nucleus  is  very  irregular  in  shape,  no  two  being  alike. 
The  protoplasm  stains  pink.  The  average  size  of  these  leukocytes  is 
13.5  micromillimeters. 

(2)  Lymphocytes,  stained  by  Wright's  method,  show  a  small 
oval  nucleus  about  the  size  of  a  red  cell  and  stain  deep  blue;  around 
the  nucleus  is  a  narrow  rim  of  protoplasm  which  stains  a  light  blue. 
At  birth,  the  lymphocytes  comprise  about  40  to  60  per  cent,  of  the 


400  DISEASES  OF  CHILDREN.  * 

total  number  of  leukocytes;  lymphocytes  vary  in  size  from  that  of  a 
red  cell  to  two  or  three  times  this  size,  and  so  are  named  large  or  small. 
In  the  large  variety,  the  nucleus  may  be  placed  eccentrically  or  in- 
dented, and  the  protoplasmic  rim  may  be  much  wider  than  in  the  small 
ones.  The  average  size  of  large  lymphocytes  is  13  micromillimeters; 
of  small  ones  10  micromillimeters. 

(3)  Eosinophiles  also  have  polymorphous  nuclei  of  much  looser 
structure  and  larger  granules  than  the  polynuclears.  With  Wright's 
method  the  nucleus  stains  a  light  blue  or  lilac  and  the  granules  a 
brilliant  pink,  the  protoplasm  staining  a  pale  blue.  The  average  size 
of  eosinophiles  is  12  micromillimeters. 

(4)  Mast  cells  are  about  twice  the  size  of  a  red  cell,  i.e.,  15  micro- 
millimeters. The  nucleus  is  usually  polymorphous.  Large  granules 
(staining  dark  blue  or  almost  black)  lie  over  and  around  the  nucleus 
and  along  the  margins  of  the  cell. 

(5)  Myelocytes  occur  only  in  pathological  conditions.  These  are 
bone-marrow  cells,  and  are  the  forerunners  of  the  polynuclear  cell. 
It  is  a  large  cell,  the  average  diameter  being  15.75  micromillimeters; 
it  differs  from  the  large  lymphocytes  in  having  granules;  it  differs 
from  the  polynuclears  only  in  the  shape  of  its  nucleus  which  is  oval 
and  not  broken  up  and  which  is  in  close  contact  with  the  cell  wall  for 
a  large  portion  of  its  extent,  i.e.,  if  egg-shaped  it  is  placed  eccentrically. 

According  to  Hayem,  the  number  of  leukocytes  per  cubic  milli- 
meter during  the  first  forty-eight  hours  of  life  averages  18,000;  falls 
to  7,000  for  the  third  and  fourth  days;  and  averages  9,000  to  11,000 
after  the  fifth  day.  The  counts  of  Schiff,  Orunsky  and  Rieder  run  con- 
siderably higher  than  this.  The  following  table  (by  Wile)  gives  the 
relative  percentage  of  polynuclears  and  lymphocytes  in  the  blood 
during  the  first  ten  years: 

Age  in 
years 

1 

2 

3 

4 

5 

6 

7 

8 

9 
10 


Polynuclear 

neutrophiles 

Lymphocytes 

35% 

53% 

38% 

51% 

42% 

.        47% 

47% 

41% 

52% 

39% 

52% 

37% 

53% 

35% 

54% 

33% 

55% 

31% 

60% 

30% 

DISEASES  OF  THE  BLOOD,  401 

Leukocytosis  (or  hyperleukocytosis),  i.e.,  an  increase  in  the 
number  of  white  blood-corpuscles  per  cubic  millimeter,  is  present  in 
the  following  pathological  conditions:  Pneumonia,  diphtheria,  per- 
tussis, scarlet  fever,  erysipelas,  rheumatism,  acute  rickets,  septic  and 
cerebrospinal  meningitis,  and  in  pus  cases,  such  as  appendicitis, 
peritonitis,  empyema,  osteomyelitis,  and  acute  abscess.  In  the  above 
conditions  the  increase  of  cells  is  in  the  polynuclears  and  is  known 
as  polynucleosis.  Leukocytosis  is  also  physiological;  e.g.,  in  the 
new-born,  after  exercise,  after  a  cold  bath,  and  after  a  full  meal;  in  this 
latter  condition  the  count  may  be  increased  33  \  per  cent. 

Leukopenia  is  a  state  of  diminished  leukocyte  count,  and  occurs  in 
typhoid,  measles,  influenza,  malaria,  tuberculous  inflammations  and 
gastroenteritis. 

Lymphocytosis  is  an  increase  in  the  number  of  lymphocytes,  and 
occurs  in  syphilis  (congenital),  scurvy  and  splenic  disease. 

EosiNOPHiLiA,  an  increase  in  the  number  of  eosinophiles,  occurs 
in  leukemia,  chronic  skin  disease,  and  in  patients  infected  with  intes- 
tinal parasites,  particularly  trichina. 

Blood- PLATES  (or  plaques)  are  best  seen  in  fresh-blood  prepara- 
tions. They  are  very  small,  round  or  oval  bodies,  about  2  to  3.5 
micromillimeters  in  diameter.  In  a  few  seconds  they  lose  their 
rounded  form  and  become  spinous,  and  ultimately  very  thin  filaments 
of  fibrin  are  seen  starting  from  their  angular  projections.  Their 
functions  are  not  known. 

Anemia. 

A  decrease  in  the  amount  of  hemoglobin  produces  a  state  known 
as  anemia.  The  decrease  may  be  in  the  total  amount  of  blood,  in  the 
total  number  of  corpuscles,  or  in  the  coloring  matter  of  the  red  cells. 
Alterations  in  the  number  of  leukocytes  do  occur  in  anemic  states, 
yet  these  changes  cannot  be  regarded  as  factors  in  the  process. 

Simple  or  Secondary  Anemia. 

These  anemias  are  more  often  secondary  to  some  of  the  severe, 
acute,  or  constitutional  diseases,  as  gastroenteritis,  syphilis,  rickets, 
tuberculosis,  nephritis,  pneumonia,  etc.  Bad  hygienic  conditions 
and  unsuitable  food  are  often  responsible  and  occasionally  fatal. 
The  nurslings  of  diseased  mothers  are  especially  liable  to  anemia. 
Loss  of  blood  from  any  cause  is  serious  in  early  life,  and  the  resulting 
anemia  occasionally  persists.  The  parasites  and  the  toxemias  produce 
anemias  of  this  type. 
26 


402  DISEASES  OF  CHILDREN. 

Pathology. — The  red  blood-corpuscles  are  diminished  in  number, 
sometimes  decreased  to  a  million  and  a  half  or  less.  The  hemoglobin 
is  lowered  to  30  per  cent.,  but  we  have  not  too  rarely  had  an  estimation 
of  10  to  15  per  cent.  Irregular  forms  are  seen  in  the  severe  types. 
Leukocytosis  in  our  experience  is  more  often  observed  than  absent 
in  early  life. 

Symptomatology. — Languor,  anorexia,  pale  or  blanched  mucous 
membranes  and  sallowness  of  the  skin  is  usually  present.  Con- 
stipation is  the  rule.  The  gastrointestinal  tract  is  early  disordered. 
Later  the  child  tires  easily  and  becomes  dyspneic  on  exertion.  The 
extremities  are  cold.  The  pulse  is  soft.  The  heart  action  is  rapid  and 
hemic  murmurs  are  heard  over  the  base  and  in  the  neck.  The  sleep 
is  broken,  and  the  temperament  changes.  While  there  is  usually  a 
steady  loss  of  weight,  augmentation  may  follow  in  aggravated  cases  of 
edema. 

The  spleen  and  liver  may  be  found  to  be  enlarged  or  enlarge  after 
some  weeks  of  illness.  These  children  are  prone  to  intercurrent 
affections  and  easily  succumb  to  a  pneumonia  or  gastroenteric 
infection. 

Differential  Diagnosis. — Lymphatic  leukemia  must  be  dis- 
tinguished if  there  is  splenic  hypertrophy  present.  The  more  intense 
blood  picture  with  its  varied  forms  establishes  the  diagnosis  together 
with  the  slower  and  more  protracted  course  resisting  ordinary 
treatment. 

In  the  pseudoleukemia  of  infants  (von  Jaksch)  we  have  a 
marked  leukocytosis  with  splenic  and  hepatic  enlargement  coupled 
with  a  hypertrophy  of  the  lymph  nodes. 

Prognosis. — The  etiological  factor  and  the  intensity  of  the 
leukocytosis  present  must  be  taken  into  consideration  in  framing  the 
prognosis.  A  low  red  blood-cell  count,  reduction  of  the  hemoglobin 
to  below  30  per  cent.,  coupled  with  a  high  color-index,  are  unfavorable 
features;  otherwise  the  prognosis  is  good. 

Chlorosis. 

This  is  an  anemia  characterized  pathologically  by  a  lowering  of 
the  hemoglobin  without  a  marked  decrease  in  the  number  of  red  cells 
and  clinically  by  a  greenish-yellow  color  of  the  skin. 

Etiology. — Girls  at  the  age  of  puberty,  especially  those  who  work 
in  factories,  or  those  who  have  deficiency  of  fresh  air  and  sunlight  are 
liable  to  chlorosis.  Boys  are  occasionally  affected.  The  stress  of 
school  duties  and  early  social  life  predispose  in  the  wealthier  classes. 


DISEASES  OF  THE  BLOOD.  403 

Pathology. — Hemoglobin  as  low  as  20  or  30  per  cent,  is  com- 
monly observed.  The  red  cells  themselves  are  somewhat  below  nor- 
mal and  the  color-index  is  lowered.  The  leukocytes  remain  normal, 
unless  complications  are  present. 

Symptomatology. — A  striking  pale  green  color  of  the  skin,  with 
pale  mucous  membranes,  in  a  well-nourished  girl  who  complains  of 
languor  and  who  has  a  capricious  appetite  are  symptoms  strongly  point- 
ing to  chlorosis.  The  blood  examination  will  confirm  the  diagnosis. 
The  disease  runs  a  chronic  course,  and  any  of  the  following  symptoms 
may  be  noted  before  the  disease  is  arrested.  Shortness  of  breath, 
hemic  murmurs  at  the  base  of  the  heart  and  in  the  large  vessels  in  the 
neck.  There  is  some  edema  of  the  finger- joints.  Rapid  heart  action 
with  palpitation,  gastric  hyperacidity,  constipation,  and  headache  are 
quite  common.  Percussion  may  show  an  enlargement  of  the  heart  to 
the  right.  The  temperament  changes,  the  patient  becoming  irritable, 
fussy,  or  even  hA'sterical. 

Diagnosis. — A  careful  examination  should  be  made  to  exclude 
tuberculosis  (see  Tuberculin  Tests),  gastric  ulcer,  and  the  status  lym- 
phaticus.     The  movements  should  be  examined  for  the  ova  of  the  in- 
testinal parasites. 

Prognosis. — This  is  good  if  radical  changes  are  made  in  the  daily 
life  of  the  patient  and  complications  can  be  excluded.  The  disease  does 
not  react  as  readily  to  iron  therapy  as  other  anemias  and  runs  a  more 
prolonged  course. 

Pernicious  Anemia. 

This  is  rare  in  early  life.  The  characteristic  blood  changes  es- 
tablish the  diagnosis.  The  red  blood-corpuscles  are  reduced  in 
number;  megaloblasts,  poikilocytosis,  polychromasia,  normoblasts 
and  megaloblasts  with  myelocytes  are  found.  The  hemoglobin 
content  is  considerably  reduced.  The  color-index  is  high.  The 
leukocytes  are  low  and  the  lymphocytes  relatively  increased.  The 
spleen,  liver,  and  glands  are  not  hypertrophied.  As  the  symptoms, 
course,  and  treatment  do  not  differ  from  those  in  adults,  they  have 
been  omitted,  the  blood  picture  being  presented  for  purposes  of  differ- 
ential diagnosis. 

Leukemia. 

This  is  an  uncommon  disease  in  infancy  and  childhood,  charac- 
terized by  a  great  increase  in  the  white  blood-cells  and  changes  in  the 
spleen,  bone-marrow,  and  lymph  nodes. 

Etiology. — In  early  life  syphilis,  rickets,  malaria,  and  the  chronic 


404 


DISEASES  OF  CHILDREN. 


affections  in  general  are  regarded  as  the  possible  causative  factors. 
Whether  there  is  a  specific  infection,  as  has  been  claimed,  is  still 
unsettled. 

Pathology  of  the  Blood. — Two  forms  are  distinguished;  the 
myelogenous  or  splenomyelogenous  leukemia  and  the  less  common 
lymphatic  form.     These  are  differentiated  by  their  blood  picture. 

Splenomyelogenous  Form. — The  white  blood-cells  are  enor- 
mously increased — 100,000  to  500,000.     Among  these  the  myelocytes 

are  found  in  large  numbers. 
The  polynuclear  neutro- 
philes  are  relatively  in- 
creased. There  is  an  in- 
crease in  the  large  mono- 
nuclears, the  polynuclear 
and  mononuclear  eosino- 
philes.  The  mast  cells  may 
be  found  in  considerable 
numbers. 

Lymphatic  Form. — 
The  lymphocytes  are  enor- 
mously increased,  forming 
nearly  the  whole  percent- 
age of  white  blood-cells. 
Myelocytes  and  mast  cells 
are  sometimes  found.  In 
both  forms  there  is  a 
diminution  in  the  amount 
of  hemoglobin  and  in  the 
number  of  red  blood-cells 
with  the  presence  of  a  few 
normoblasts. 

Symptomatology. — The 
onset  may  be  acute,  but  a 
slow  insidious  onset  is  the  rule.  The  pallor  of  the  skin  and  mucous 
membranes  with  digestive  disturbance  may  be  the  first  symptoms 
noticed,  or  a  sudden  hemorrhage  from  the  nose  or  blood  in  the  stools 
may  first  attract  attention.  Vomiting  and  diarrhea  become  more 
and  more  frequent.  Falls  easily  cause  ecchymotic  areas.  The  ab- 
domen is  tympanitic  and  protuberant,  and  in  one  of  our  cases  this 
was  the  first  symptom  to  attract  the  mother's  attention.  The  spleen 
is  found  enlarged  and  may  touch  the  crest  of  the  ilium.  It  may  be 
tender  on  palpation. 


Fig.  107. — Leukemia;  markings  show 
enlargement  of  liver  and  spleen. 


DISEASES  OF  THE  BLOOD.  '405 

The  lymph  nodes  are  quite  generally  involved,  especially  the 
cervical  group.  On  rectal  examination  the  mesenteric  nodes  are 
found  palpable.  Even  the  lymphoid  structures  in  the  nasopharynx 
are  hypertrophied.  The  liver  is  found  enlarged  and  assists  in  making 
more  striking  the  general  abdominal  enlargement.  As  the  disease 
advances,  dyspnea,  rapid  heart  action,  and  obstinate  constipation 
are  in  evidence.  The  child  becomes  somnolent,  refuses  food,  and 
dies  of  exhaustion. 

Prognosis. — It  is  a  fatal  disease  in  the  pure  types. 

Pseudoleukemia  of  Infants. 

(von  Jaksch's  Anemia). 

There  has  been  and  still  is  much  diversity  of  opinion  with  regard 
to  the  disease  having  a  distinct  entity.  We  have  had  cases  that 
conformed  quite  closely  to  von  Jaksch's  description  and  which  seemed 
to  develop  from  a  long-continued  severe  anemia.  The  disease  is 
characterized  by  a  grave  anemia  with  leukocytosis,  enlargement  of 
the  spleen,  liver,  and  lymph  nodes. 

Etiology. — Infants  who  have  had  secondary  anemias  or  who 
have  rickets  and  syphilis  are  predisposed. 

Pathology.  Blood. — The  red  blood-corpuscles  are  diminished  to  as 
low  as  two  millions.  Microcytes,  megalocytes,  and  poikilocytes  are 
found.  Nucleated  red  cells,  normoblasts,  and  megaloblasts  may  be  found. 

The  white  blood-cells  are  proportionately  increased  up  to  50,000 
or  more.  The  differential  count  shows  an  increase  in  the  mononuclears 
and  polynuclears.  The  eosinophiles  may  also  be  increased.  Myelo- 
cytes are  seen,  but  are  few  in  number. 

Symptomatology. — The  infant  is  extremely  pale,  sallow,  or  cachec- 
tic. Slow  but  progressive  emaciation  is  the  rule.  The  infant  shows 
little  or  no  interest  in  its  surroundings.  The  appetite  is  small  and 
intestinal  indigestion  is  frequent.  The  cervical  lymph  nodes  are 
palpable  and  the  liver  and  especially  the  spleen  are  enlarged.  The 
spleen  is  easily  palpable,  feels  hard,  and  it  is  not  painful.  The  infant 
may  die  of  exhaustion  or  a  complicating  bronchopneumonia. 

Differential  Diagnosis. — From  leukemia  it  is  sometimes  with 
difficulty  differentiated,  but  the  lower  leukocyte  count,  the  scarcity  of 
myelocytes,  the  less  pronounced  hepatic  and  lymph  node  hypertrophy 
will  aid  in  classifying  the  disease. 

Prognosis. — This  must  be  regarded  as  a  grave  blood  disorder. 

The  principal  anemias  are  tabulated  in  the  following  chart  with 
the  blood  conditions  briefly  enumerated: 


406 


DISEASES  OF  CHILDREN. 


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DISEASES  OF  THE  BLOOD. 


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408  DISEASES  OF  CHILDREN. 

Treatment  of  the  Anemias. 

The  general  management  of  these  cases  is  of  greater  importance 
than  the  administration  of  drugs.  The  causes  which  have  produced 
the  anemia  may  or  may  not  be  clear,  but  the  majority  of  cases  are  in 
all  events  benefited  by  a  regulation  of  their  daily  life.  If  the  causa- 
tive agent,  as  parasites,  is  found,  treatment  should  be  directed  to- 
ward its  removal.  Sunshine  and  fresh  air  coupled  with  an  easily 
assimilated  diet  as  rich  in  proteids  and  organic  iron  as  possible,  should 
be  considered  as  necessities  for  all  the  anemias. 

Aerotheraphy  may  be  limited  by  the  circumstances  as  in  the  case 
of  the  poor  city  child,  but  five  hours  a  day  in  the  open  air  can  always 
be  obtained  even  in  the  winter  months  by  using  the  child's  room,  the 
roof,  or  the  parks. 

The  children  are  more  benefited  when  removed  to  the  country. 
If  the  child  has  been  attending  school,  this  should  be  discontinued 
and  the  amount  of  exercise  curtailed.  Rest  in  bed  is  necessary  for 
the  severe  cases,  but  this  should  not  preclude  sun  baths  and  fresh-air 
treatment.  If  possible  the  child  should  be  cared  for  and  entertained 
by  one  person  so  as  to  avoid  undue  excitement  or  fatigue. 

A  bottle-fed  infant  should  gain  in  weight  and  strength  if  the 
formula  is  suitable  to  its  requirements.  If  assimilation  is  at  fault 
a  wet-nurse  may  be  required,  or  such  changes  and  additions  should 
be  made  to  the  food  as  will  at  least  temporarily  promote  the  digestive 
capacity.     (See  article  on  Infant  Feeding.) 

Older  children  should  have  an  individual  diet  list  prepared  for 
them  which  will  contain  especially  such  articles  as  fresh  raw  milk, 
eggs,  vegetables,  rare  meats,  and  fresh  fruits.  (See  Diet  Lists,  p.  174.) 
Spinach,  yolk  of  egg,  and  the  legumes  contain  organic  iron  in  largest 
quantities,  and  it  is  desirable  that  the  deficiency  in  iron  should  be 
made  up  from  the  natural  foods  rather  than  iron  preparations. 

Drugs. — In  chlorosis  the  iron  preparations  are  of  distinct  value, 
especially  when  given  with  a  nutritious  diet  and  baths.  Many  of  the 
anemias  are  benefited  by  the  scale  preparations,  especially  the 
citrate  of  iron  and  ammonia  and  the  bitter  wine  of  iron.  Several 
trials  may  be  required  to  find  the  preparation  of  iron  best  suited  to 
the  individual  case.  The  various  peptonates  often  do  well,  as  they  are 
easily  tolerated  by  the  stomach,  but  other  cases  will  apparently  do 
better  on  the  old  tincture  of  the  chlorid  of  iron,  well  diluted  and  given 
through  a  tube.  In  older  children,  Blaud's  pill  will  often  do  good 
service.  Fowler's  solution  should  be  given  in  addition  to  the  leuke- 
mias  and  in  pernicious  anemia,  beginning  with  one  drop  three  times 


DISEASES  OF  THE  BLOOD.  409 

a  day  well  diluted  and  gradually  increasing  to  the  physiological  result, 
care  being  taken  not  to  produce  symptoms  of  arsenical  neuritis.  Cod- 
liver  oil  is  a  valuable  addition  if  it  is  well  borne  and  does  not  produce 
an  aversion  to  the  ordinary  diet. 

We  have  used  the  X-rays  in  selected  casesof  splenic  leukemia,  but 
the  results  which  at  first  seemed  promising  do  not  warrant  its  general 
use. 

Purpura. 

In  this  condition  subcutaneous  hemorrhages,  petechial  or  ecchy- 
motic  in  type,  appear  spontaneously  and  form  one  of  the  symptoms 
of  a  disease.  Different  names  have  been  applied  varying  with  the 
location  and  extent  of  the  hemorrhages. 

It  is  known  as  purpura  simplex  when  the  hemorrhages  occur  into 
the  skin  only,  and  purpura  hemorrhagica  when  bleeding  takes  place 
into  the  mucous  membranes  or  internal  organs. 

Etiology. — Any  infectious  process  at  any  time  during  its  course 
may  be  accompanied  with  purpura.  It  especially  occurs  in  children 
with  scarlet  fever,  variola,  measles,  cerebrospinal  meningitis,  and 
with  septic  processes  in  any  organ. 

Pathology. — Hemorrhagic  exudates  may  be  found  varying  with 
the  type  of  the  disease  either  in  the  skin,  mucous  membranes,  or 
internal  organs,  or  in  all  of  these  situations.  The  spleen  is  enlarged 
in  those  types  occurring  with  marked  infection.  The  study  of  the 
blood  has  thus  far  thrown  no  light  on  the  pathology  of  the  disease. 
Further  study  of  the  adrenal  bodies,  which  sometimes  show  large 
hemorrhages,  may  explain  the  etiology  of  the  disease  and  prove 
whether  it  is  an  infectious  process,  a  pathological  change  in  the 
arteries  themselves,  or  whether  it  is  due  to  vasomotor  changes  that 
allow  the  hemorrhage  to  take  place. 

Purpura  Simplex. — The  purpura  may  appear  suddenly  in  a  child 
that  is  apparently  well,  but  as  a  rule  it  is  preceded  by  prodromal 
symptoms  resembling  those  of  intestinal  disturbance.  There  may  be 
lassitude,  loss  of  appetite,  even  nausea  or  vomiting.  The  stools  may 
be  slimy  from  improper  digestion,  and  a  low  grade  of  fever  is  present 
in  older  children,  but  little  or  no  variation  is  noted  in  infancy.  The 
tibial  surfaces  are  usually  first  involved,  the  hemorrhagic  areas  varying 
greatly  in  extent  in  different  subjects.  The  color  soon  changes  from  a 
purplish-red  to  a  dark,  mottled,  bluish-black.  There  is  no  pruritus 
nor  pain  on  pressure  over  these  areas.  Indefinite  muscle  or  joint 
pains  are  complained  of,  but  localized  with  difficulty. 

In  cachectic  or  marasmus  infants  it  is  not  uncommon  to  see  these 


410 


DISEASES  OF  CHILDREN. 


hemorrhagic  areas  appear  over  the  abdomen  or  extremities.  In  any 
long-standing  or  exhausting  disease  in  the  early  months  of  life,  purpura 
may  appear  and  must  be  regarded  as  of  serious  import. 

In  older  children,  however,  purpura  simplex  tends  to  recovery, 
although  relapses  sometimes  occur  when  the  outlook  seems  most 
bright. 

Purpura  Hemorrhagica. — In  contrast  to  the  simple  form,  this  is  a 
much  more  serious  condition  with  a  rather  severe  train  of  symptoms. 
After  a  few  days  of  indisposition,  with  nausea  and  vomiting,  fever 


Fig.  108. — Purpura  hemorrhagica. 


appears  ranging  from  100°  to  104°  F.,  with  prostration  out  of  propor- 
tion to  the  symptoms.  At  the  same  time  that  the  hemorrhages  appear 
in  the  skin,  there  may  be  bleeding  from  the  nose  or  mouth.  Hemor- 
rhages in  the  alimentary  tract  may  occur  and  are  noted  by  finding 
blood  in  the  vomitus  or  in  the  stools.  The  fact  must  not  be  forgotten, 
however,  that  the  blood  may  be  swallowed  and  later  appear  in  the 
vomitus  or  stools.  Blood  in  the  urine  usually  occurs  in  the  beginning, 
but  ceases  when  the  child  is  put  at  rest.  Localized  areas  of  edema 
may  be  present  and,  as  a  rule,  correspond  to,  although  greater  than, 
the  hemorrhagic  areas.  Pain  referred  to  the  gastric  region,  headache, 
and  anorexia  are  quite  common  symptoms  which  persist  in  spite  of 
treatment.     Sleep  is  broken,  and  delirium,  especially  at  night,  may 


DISEASES  OF  THE  BLOOD. 


411 


occur.     Coma  resembling  that  of  the  typhoidal  state  occurs  in  the 
severe  cases  and  may  persist  until  a  fatal  issue  takes  place. 

Henoch's  Purpura. — This  symptom-complex,  occurring  as  a  rule 
in  childhood,  was  first  described  by  Henoch.  The  symptoms  refer- 
able to  the  skin  consist  of  a  purpura  of  varying  degree,  often  accom- 
panied by  an  exudative  erythema  and  urticaria  or  a  localized  edema. 
Besides  the  above  manifestations,  there  are  lesions  in  one  or  more 
joints  which  resemble  rheumatic  fever.     Colicky  pains,  with  vomiting 


Fig.  109. — Henoch's  purpura. 


and  diarrhea,  are  nearly  always  present,  but  as  a  rule  are  not  of  long 
duration.  As  in  purpura  hemorrhagica,  there  may  be  hematuria  or 
hematemesis.  Albumin  is  generally  found  in  the  urine.  Recur- 
rences are  frequent  and  succeeding  attacks  may  show  wide  varia- 
tions in  the  symptoms. 

Schbnleins  Purpura.  {Purpura  Rheumatica.) — This  form  is  char- 
acterized by  a  polyarthritis  with  the  symptoms  of  rheumatic  fever  and 
purpuric  hemorrhages.  Circumscribed  edema  may  be  present.  A 
variable  amount  of  temperature  occurs  with  the  arthritis.  Albumin 
is  generally  found  in  the  urine. 

Purpura  Fulminans. — A  very  rare  but  fatal  form  of  purpura  is 
designated  as  a  fulminant  type.     The  onset  is  sudden,  occurring  with 


412  DISEASES  OF  CHILDREN. 

high  fever,  convulsions  or  chills,  vomiting,  and  marked  prostration. 
The  purpuric  eruption  rapidly  spreads  over  the  whole  body.  The 
urine  is  scant  and  contains  albumin.  It  most  frequently  occurs  in 
children  under  five  years  of  age,  and  what  was  formerly  known  as 
malignant  or  black  scarlet  fever  and  measles  probably  belong  to  this 
type.     Hemorrhages  into  the  adrenals  have  been  recorded. 

Diagnosis. — The  diagnosis  of  purpura  is  usually  easily  made  from 
the  hemorrhagic  nature  of  the  lesions  which  do  not  disappear  upon 
pressure.  It  is  to  be  distinguished  from  infantile  scurvy  in  which 
there  are  present  swollen,  spongy,  bleeding  gums,  and  articular  pain 
combined  with  a  long  history  of  cooked  food. 

Prognosis. — In  certain  forms,  as  the  simple  and  rheumatic,  the 
prognosis  is  favorable,  although  it  may  persist  for  several  weeks. 
Hemorrhagic  purpura  and  Henoch's  purpura  have  sometimes  been 
attended  with  fatal  results.  The  fulminant  type  is  always  dangerous 
to  life. 

Treatment. — This  must  necessarily  be  directed  to  the  under- 
lying cause  when  this  is  known.  Rest  in  bed  with  a  carefully  regu- 
lated diet,  including  raw  fruit  juices,  is  indicated.  The  fluid  extract  of 
ergot  internally  or  5  minims  of  a  yoW  adrenalin  solution  hypoder- 
matically  may  be  given  if  the  hemorrhages  are  profuse.  In  convales- 
cence the  tincture  of  the  chlorid  of  iron  is  important. 

Hemophilia. 

Hemophilia  is  an  hereditary  blood  disorder  characterized  by  a 
tendency  to  inordinate  bleeding  from  the  vessels  following  a  trauma, 
or  spontaneously  from  the  capillaries  into  the  tissues. 

It  is  almost  invariably  transmitted  through  the  mother,  who 
herself  may  not  have  been  a  bleeder.  The  male  offspring  (the  first 
born  often  escaping)  is  affected  in  the  proportion  of  eleven  to  one  of 
the  female.  The  male  may  again  transmit  the  disease  through  his 
daughter. 

No  characteristic  blood  changes  or  histological  peculiarity  of  the 
vessels  has  been  found.  Coagulation  is  always  retarded.  The 
hemorrhages  occur  most  frequently  from  the  nose,  mouth,  genital 
organs,  and  lungs.  Some  trauma  to  these  parts  may  be  the  first  notice 
of  the  diathesis  or  the  fact  that  slight,  almost  imperceptible  blows 
produce  subcuticular  hemorrhages.  Following  a  fall  there  may  be 
internal  hemorrhage  or  bleeding  into  a  joint  that  may  produce  dis- 
ability or  subsequent  anchylosis.  Death  has  occurred  from  uncontroll- 
able hemorrhage  following  circumcision  or  the  extraction  of  a  tooth. 


DISK\SES  OF  THE  BLOOD.  413 

Treatment. — Marriages  in  the  families  of  bleeders  should  be  con- 
trolled or  at  least  due  warning  of  consequences  given. 

Subcuticular  hemorrhages  are  sometimes  controlled  by  absolute 
rest  with  ice  applications  and  compression.  Adrenalin  1-1,000  or 
1-500  adrin  solution  may  be  directly  applied.  Stypticin  in  doses  of 
gr.  ^  offers  some  hope  of  control.  The  gelatin  solutions  for  subcu- 
taneous use  are  to  be  deprecated,  as  they  may  be  carriers  of  tetanus 
infection.  Warm  or  rather  tropical  climates  are  the  safest  for  the 
hemophiliac. 


CHAPTER  XXXI. 
DISEASES  OF  THE  DUCTLESS  GLANDS. 

The  Thymus. 

This  small,  ductless  gland,  of  epithelial  origin,  consists  of  two  lobes 
coming  in  contact  in  the  median  line.  It  is  located  during  its  greatest 
development  partly  in  the  lower  part  of  the  neck  and  partly  on  the 
anterior  mediastinum,  extending  from  the  lower  edge  of  the  thyroid 
above  to  the  fourth  costochondral  articulation  below.  It  is  thus  in 
relation  with  the  trachea  above  and  the  great  vessels  and  pericardium 
below.  It  is  largest  during  the  first  two  years  of  life  and  then  atro- 
phies, but  occasionally  it  persists  longer  and  may  last  until  puberty. 
In  the  course  of  atrophy  it  disappears  from  the  neck  and  remains 
behind  the  manubrium.  Various  authorities  disagree  as  to  its  normal 
weight.  From  14  to  20  grams  are  said  to  be  the  average  weight 
during  infancy,  but  Boviard  finds  it  much  smaller  than  usually  stated. 
From  100  observations  made  on  the  normal  size  of  the  thymus  in  early 
life,  he  found  it  averaged  not  over  3  grams,  in  weight.  The  histo- 
logical structure  of  the  thymus  is  similar  to  that  of  lymph-glands,  and 
it  probably  functionates  as  a  blood-forming  organ. 

Enlargement  of  the  Thymus. 

Hypertrophy  of  the  thymus  may  produce  grave  effects  apparently 
from  pressure.  Two  possible  explanations  may  be  offered — first, 
that  the  enlarged  thymus  pushes  on  the  trachea  and  thus  embarrasses 
breathing;  second,  that  dyspnea  may  be  caused  by  pressure  on  the 
phrenics  or  pneumogastrics.  It  is,  however,  difficult  to  prove  the  lat- 
ter. Laryngismus  stridulous  and  various  forms  of  dyspnea,  some- 
times called  "thymic  asthma,"  have  been  referred  to  the  enlarged 
thymus.     The  symptoms  may  eventuate  in  sudden  death. 

The  diagnosis  of  enlarged  thymus  by  physical  signs  is  rarely 
made  positively  during  life.  It  may  occasionally  be  palpated  by 
deep  pressure  over  the  top  of  the  sternum  and  there  may  be  dullness 
on  percussion  behind  the  upper  part  of  the  manubrium  extending 
down  from  both  lateral  borders  of  the  sternum.  The  area  of  dullness 
on  the  sides  of  the  sternum  may  be  unsymmetrical. 

414 


DISEASES  OF  THE  DUCTLESS  GLANDS. 


415 


P'iG.  110 — Marked  enlargement  of  the  thymus  gland  with  its  relations; 
from  an  infant,  7  months  old. 


416  DISEASES  OF  CHILDREN. 

Status  Lymphaticus. 

By  this  condition  is  understood  a  lowered  vitality  seen  in  con- 
nection with  enlarged  thymus  and  a  general  hyperplasia  of  the  lym- 
phoid tissue  of  the  body.  Sudden  death  from  cardiac  paralysis  and 
asphyxia  may  ensue  under  anesthesia  or  from  any  intercurrent  disease 
or  irritation.  Enlargement  may  be  noted  of  the  superficial  and  deep 
lymph  nodes  of  the  neck,  of  the  follicles  at  the  root  of  the  tongue, 
of  the  tonsils,  of  the  adenoid  tissue  at  the  vault  of  the  pharynx,  and, 
on  autopsy,  of  the  lymphoid  structures  of  the  stomach  and  bowels. 
There  may  be  some  enlargement  of  the  spleen  with  hypertrophy  of 
the  Malpighian  bodies.  There  may  likewise  be  a  proliferation  of  the 
lymphoid  tissue  of  the  bone-marrow.  Drs.  Musser  and  Ullom  report 
the  pathological  findings  to  be  practically  constant  in  eighteen  cases 
of  status  lymphaticus  collated  from  the  literature  of  the  subject, 
consisting  of  an  enlarged  thymus,  spleen,  lymph  glands,  Peyer's 
patches,  tonsils  and  pharyngeal  tissue.  While  these  conditions  were 
not  reported  in  every  case,  the  enlarged  thymus,  spleen,  and  some  of 
the  lymph-glands  were  constantly  found.  Cloudy  swelling  of  the 
liver  and  kidney  were  also  fairly  constant  lesions.  German  path- 
ologists, especially  Virchow,  have  noted  a  lack  of  development  of  the 
heart  and  arteries.  Thus  the  heart  may  be  small  and  the  aorta  narrow 
and  thin-walled.  With  this  may  be  associated  a  lack  of  development 
of  the  sexual  organs  sometimes  reaching  the  condition  of  infantilism. 
Varying  grades  of  rickets,  with  resulting  mild  or  severe  bony  defor- 
mities, are  seen  in  a  large  number  of  cases  of  status  lymphaticus.  These 
children  may  show  a  fair  amount  of  fatty  tissue,  but  are  usually 
anemic.     Chlorosis  or  hemophilia  may  also  exist. 

It  is  very  probable  that  the  disastrous  results  so  often  seen  in 
status  lymphaticus  are  due  to  an  autointoxication  from  a  sort  of 
lymphotoxemia  having  its  source  in  the  lymphatic  tissues  of  the  body. 
The  importance  of  recognizing  the  condition  is  very  great  not  only  in 
respect  to  anesthesia,  but  for  guarding  the  prognosis  in  any  intercurrent 
mild  or  severe  disease  and  as  an  explanation  of  certain  cases  of  sudden 
death  without  any  known  cause. 

The  diagnosis  often  cannot  positively  be  made,  but  children  or 
young  adults  with  bony  evidences  of  rickets,  with  much  enlarged 
tonsils  and  adenoids,  with  generally  hypertrophied  lymph-glands, 
with  the  male  genital  organs  or  breasts  undeveloped  in  the  older 
subjects,  together  with  an  absence  of  pubic  hair,  should  be  considered 
as  possible  subjects  of  status  lymphaticus. 

In  young  subjects,  attacks  of  laryngospasm,  in  conjunction  with 


DISEASES  OF  THE  DUCTLESS  GLANDS.  417 

a  number  of  these  stigmata  will  greatly  strengthen  the  diagnosis. 
Congenital  underdevelopment  of  the  heart  and  arteries  is  usually 
accompanied  by  smallness  of  the  surface  arteries  and  a  small  pulse. 

The  treatment  consists  in  careful  hygienic  oversight,  especially 
as  regards  food,  fresh  air,  and  warm  clothing.  Cod-liver  oil  and  the 
syrup  of  the  iodid  of  iron  may  be  given.  The  hypertrophied  tonsils 
and  adenoids  must  be  early  removed,  but  without  the  administration 
of  an  anesthetic. 

Diseases  of  the  Spleen. 

The  spleen  is  not  uncommonly  found  to  be  enlarged  in  infants 
and  children.  Its  elastic,  distensible  structure  makes  it  peculiarly 
susceptible  to  enlargement,  especially  from  congestion,  infectious, 
blood,  or  constitutional  disorders. 

Its  upper  border  lies  on  a  line  with  the  ninth  rib,  its  lower  border 
reaching  to  the  eleventh  rib.  It  is  a  safe  rule  to  say  the  spleen  is  not 
enlarged  if  it  cannot  be  palpated  below  the  ribs.  The  position  for 
palpation  should  be  that  described  on  page  44/  Fig.  11. 

Inflammation  of  the  Spleen. 

This  occurs,  as  a  rule,  from  a  neighboring  process  or  from  trauma. 
Perisplenitis  may  occur  in  syphilis,  tuberculosis,  peritonitis,  and 
injuries.  Older  children  may  refer  their  pain  accurately  to  the  splenic 
region.  In  some  cases  a  friction  rub  is  distinctly  felt.  With  the 
stethoscope  a  coarse  friction  sound,  not  unlike  that  in  pleuris}-,  can 
be  heard. 

Chronic  Passive  Congestion  of  the  Spleen. 

This  is  seen  in  connection  with  enlargement  of  the  liver,  tuber- 
culosis, and  in  cardiac  affections. 

Other  Enlargements  of  the  Spleen. — Sarcoma,  although  rare, 
has  been  observed  as  a  primary  condition.  The  tuberculous  and 
syphilitic  enlargements  are  nodular  and  irregular.  Primary  spleno- 
megaly is  accompanied  by  enlargement  of  the  liver  and  anemia. 
Hydatid  cysts  and  abscesses  have  been  reported,  but  are  extremely 
rare. 

Disorders  of  the  Adrenals. 

Reports  of  sudden  deaths  from  hemorrhageis  ifito  the  adrenals 
have  increased  the  importance  of  these  structures  in  early  life.     In 
27 


418  .  DISEASES  OF  CHILDREN. 

infants  they  are  relatively  larger,  and  destruction  of  their  function, 
whatever  it  may  be,  is  attended  with  serious  results. 

Hemorrhage  into  the  Adrenal. — The  symptoms  come  on 
suddenly  not  unlike  an  acute  infection.  There  may  be  vomiting  and 
diarrhea  with  acute  abdominal  pain  and,  in  some  instances,  a  pur- 
puric rash.  The  pulse  is  weak,  the  pallor  is  marked,  and  coma  or 
convulsions  may  usher  in  the  rapidly  fatal  endings. 

Addison's  Disease. 

This  is  extremely  rare  in  early  life  and  is  accompanied  by  the 
same  symptoms;  that  is,  slow  progressive  cachexia  and  bronzing  of 
the  skin  as  in  adults.  In  nearly  all  cases  tuberculosis  of  the  structure 
is  found  on  postmortem  examination. 

The  course  is  slow,  sometimes  extending  over  years,  and  the  prog- 
nosis invariably  bad. 

Treatment. — Restriction  of  muscular  exercise  and  the  general 
treatment  suitable  for  the  tuberculous  is  indicated;  the  feeding  of 
adrenal  products,  as  the  desiccated  extract  or  glycerinated  extract, 
may  be  employed  or  adrenalin  in  solution  may  be  given. 

Hodgkin's  Disease. 

(Adenie;  Lymphadenoma;  Pseudoleukemia.) 

This  disease  very  rarely  occurs  in  children.  The  main  features  are 
painless,  progressive  glandular  enlargement,  usually  beginning  in 
the  cervical  region,  and  without  the  blood  changes  of  leukemia;  en- 
largement of  the  spleen  and  liver  and  a  pronounced  anemia;  either 
tuberculosis  or  syphilis  may  be  associated,  but  in  all  probability 
neither  of  these  conditions  bears  any  relation  to  Hodgkin's  disease. 

Symptomatology. — The  enlargements  generally  first  appear  in 
the  neck.  The  glands  slowly  but  steadily  enlarge.  They  are  not  pain- 
ful to  the  touch.  The  axillary  and  inguinal  regions  are  later  involved. 
When  the  general  health  begins  to  be  affected  it  will  be  found  that 
both  the  superficial  and  deep  glands  are  affected.  From  their  posi- 
tion the  nodes  may  produce  various  pressure  symptoms,  such  as  dysp- 
nea or  dysphagia.  In  the  later  stages  pronounced  cachexia  develops 
with  an  irregular  or  remittent  type  of  fever.  The  glands  never  tend 
to  suppuration,  although  they  may  fuse  and  form  large  tumors. 

Differential  Diagnosis. — It  is  distinguished  from  chronic  adenitis 
by  the  history,  the  localization,  and  absence  of  cachexia.  Tuberculin 
or  the  various  tuberculin  tests  would  be  required  to  distinguish  it  in 


DISEASES  OF  THE  DUCTLESS  GLANDS.  419 

the  absence  of  suppuration.  Excision  of  a  lymph  node  for  histological 
examination  is  the  safest  course  for  absolute  diagnosis. 

Treatment. — Thus  far  this  has  been  quite  unsatisfactory.  Unless 
the  diagnosis  is  made  when  only  a  few  glands  are  involved  surgical 
removal  is  not  advisable. 

The  Roentgen  rays  have  given  some  good  results,  but  this  should 
only  be  used  by  those  accustomed  to  the  work.  Arsenic  may  be  given 
in  large  doses  in  the  form  of  Fowler's  solution.  Out-door  life  at  the 
seashore  is  to  be  preferred. 

Acute  Adenitis. 

This  is  an  acute  inflammation  of  the  lymph-glands  producing 
hypertrophy  of  their  structure. 

Clinically  the  lymphatic  glands  are  of  great  importance,  their 
function  being  to  guard  the  circulatory  system  since  they  are  obliged 
to  take  up,  destroy,  neutraUze,  or  at  least  hold  in  abeyance  the  num- 
berless bacteria  which  block  their  channels,  and  it  is  only  when  over- 
whelmed and  overpowered  by  these  germs  that  they  themselves  be- 
come affected. 

Recent  investigations  along  these  lines  have  sufficiently  proved 
that  inflammation  of  the  lymphatic  glands  is  due  to  absorption,  from 
a  more  or  less  distant  focus,  of  bacteria  or  their  toxins. 

Accepting  the  crude  classification  of  inflamed  glands  into  acute 
and  chronic  we  find  that  the  glands  most  frequently  affected  are 
the  cervical,  mesenteric,  axillary,  inguinal,  bronchial,  and  mediastinal. 

The  majority  of  children  with  enlarged  glands  have  cervical 
adenitis.  This  is  accounted  for  by  the  delicate  epithelium  of  the  skin 
of  the  face  and  neck  and  the  mucous  membrane  of  the  mouth  and  the 
pharynx.  These  being  largely  exposed  to  irritations,  to  bacteria,  and 
to  traumatism,  we  find  the  glands  easily  overpowered.  It  is  always 
necessary  to  seek  the  cause  or  focus  of  the  trouble  and,  if  possible, 
to  remove  it. 

Remembering  that  the  superficial  glands  drain  the  side  of  the 
head  and  neck,  face  and  external  ear,  and  that  the  deeper  glands  drain 
the  mouth,  tonsils,  palate,  pharynx,  and  larynx,  we  have  a  clue  to  the 
initial  trouble.  It  is  not  to  be  forgotten  that  the  primary  focus  may 
have  cleared  up  or  may  have  been  apparently  cured  and  forgotten,  but 
still  the  glands  remain  enlarged.  A  careful  history  of  the  eruptive 
and  infectious  diseases  must  be  obtained;  any  irritations  of  the  scalp, 
diseases  of  the  ear,  eyes,  nose,  throat,  gums,  or  teeth  must  be  taken 
into  consideration.     The  importance  of  working  backward  from  the 


420  DISEASES  OF  CHILDREN. 

effect  to  the  cause  in  these  cases  must  be  kept  in  mind.  Either  the 
superficial  or  deep  nodes  may  be  affected.  Under  two  years  of  age 
the  external  glands  are  affected  in  the  majority  of  cases,  and  thej^  also 
have  a  greater  tendency  to  undergo  suppuration.  When  the  latter  is 
about  to  take  place  the  gland  becomes  painful  and  tender  and  the  over- 
lying skin  is  reddened.  Restlessness  and  some  degree  of  temperature 
is  observed.  As  a  rule,  this  takes  place  during  the  second  week  or  it 
may  be  held  in  check  by  cold  applications  and  result  later.  A  spon- 
taneous discharge  of  pus  does  not  occur  until  the  entire  gland  has  been 
disintegrated.  Occasionally  there  seems  to  be  no  apparent  cause 
except  anemia  and  debility  for  the  glandular  hypertrophy,  but  here 
we  have  a  valuable  clue  to  the  treatment. 

The  glands  may  at  first  show  no  acute  inflammatory  changes;  they 
grow  steadily  and  surely,  and  do  not  easily  break  down.  Because  of 
the  slow  growth  and  painless  tumor,  and  with  no  local  cause  observable, 
we  are  justified  in  presuming  the  glands  to  be  tuberculous.  The  tuber- 
culin test  (page  54)  should  be  made.  Such  a  condition  by  no  means 
signifies  that  the  child  has  pulmonary  tuberculosis,  although  having 
once  given  entrance  to  these  germs  the  possibility  of  an  extension  is 
present.  The  cervical  glands  may  infect  the  thoracic  chain  and  thus 
infect  the  lungs. 

Chronic  Adenitis. 

This  may  occur  as  a  result  of  frequent  attacks  of  acute  adenitis 
or  from  persistent  local  lesions  in  the  neighboring  structures.  It  is 
also  observed  in  children  who  are  the  subjects  of  status  lymphaticus. 
The  glands  must  be  differentiated  from  tuberculous  lymph  nodes 
or  those  seen  in  Hodgkin's  disease. 

Thoracic  adenitis  is  in  greater  part  of  the  chronic  type  and  very 
often  the  glands  are  tuberculous.  Loomis  has  examined  and  found 
the  tubercle  bacillus  in  apparently  normal  glands.  We  may  safely 
say  that  in  a  large  proportion  of  tuberculous  cases  in  children  it  would 
appear  that  the  primary  infection  was  in  these  structures  and  that, 
contrary  to  Parrot's  law,  clinical  experience  shows  that  the  glands 
may  be  involved  without  local  lesions  in  the  lungs. 

In  a  large  number  of  autopsies  in  children,  we  have  found  the 
mediastinal  and  bronchial  lymph-glands  enlarged,  sometimes  pressing 
on  the  great  vessels  or  against  the  bronchial  tubes.  In  one  case  per- 
foration of  the  cheesy  bronchial  gland  into  the  adjacent  lung  was  the 
cause  of  death.  We  cannot  describe  any  definite  symptoms  invariably 
produced  by  these  pathological  glands,  but  occasionally  we  do  get  a 


DISEASES  OF  THE  DUCTLESS  GLANDS.  421 

persistent  irritative  cough  caused  by  pressure  on  a  bronchus  or  on  the 
recurrent  laryngeal  nerve,  or  localized  feeble  breathing  with  sibilant 
rales  due  to  compression  of  a  bronchus.  Percussion  is  unreliable,  for 
the  dullness  may  be  due  to  the  thymus.  Recurrent  attacks  of  bron- 
chitis may,  however,  often  be  traced  to  hypertrophied  lymph  nodes 
in  the  thorax. 

The  enlarged  mesenteric  and  retroperitoneal  glands  of  the 
abdominal  cavity  may  alone  give  sufficient  evidence  of  the  old- 
fashioned  tabes  mesenterica.  The  point  of  entrance  of  the  offending 
germs  in  these  cases  is  through  the  mucous  membrane  of  the  intestinal 
canal.  If  we  find  a  general  enlargement  of  the  glands  all  over  the  body 
— a  condition  which  Legrouz  called  microadenopathy,  we  have  a 
valuable  hint  in  doubtful  cases  of  general  tuberculous  infection.  On 
the  other  hand,  the  absence  of  hypertrophied  lymph-glands  and  the 
enlargement  of  the  liver  and  spleen  is  an  important  negative  sign  in 
chronic  diffuse  tuberculosis,  provided  we  can  rule  out  syphilis  by  the 
history  of  skin  rashes,  fissures,  and  the  therapeutic  test;  for  here  also 
we  may  have  enlargement  of  the  superficial  glands.  The  glands, 
therefore,  may  assist  in  establishing  a  correct  diagnosis;  they  may 
point  out  by  their  anatomical  distribution  the  source  of  their  own 
infection,  or  they  may  themselves  be  productive  of  pathological  con- 
ditions in  adjacent  viscera. 

Treatment.  (Acute.) — As  has  been  above  pointed  out  the  removal 
of  the  local  focus  of  irritation  is  most  important.  If  seen  early  the 
application  of  the  ice  bag  or  cold  compresses  may  cause  a  subsidence  of 
the  process.  The  application  of  a  5  to  10  per  cent,  ointment  of 
ichthyol  is  also  effective.  If  suppuration  has  begun  the  local  appli- 
cation of  heat  will  hasten  the  process.  Incision  and  drainage  are 
then  indicated. 

(Chronic.) — Any  underlying  cause  as  a  chronic  eczema,  adenoids 
and  hypertrophied  tonsils  or  a  sinus  must  be  removed  before  treat- 
ment can  be  effective. 

The  syrup  of  the  iodid  of  iron  must  be  given  for  a  long  period. 
The  X-ray  treatment  has  given  some  good  results. 

Exophthalmic  Goiter. 
(Grave's  Disease;  Basedow's  Disease.) 

This  condition,  which  is  rare  in  early  life,  is  due  to  an  increase 
in  the  growth  and  activity  of  the  thyroid  gland.  Our  cases  have 
occurred  at  or  about  the  time  of  puberty,  especially  in  girls  of  the 
neurotic  type.     Hyperemic  goiters  occurring  at  the  time  of  puberty 


422  DISEASES  OF  CHILDREN. 

must  be  distinguished  from  true  Basedow's  disease.  Tachycardia  is 
present  in  both  conditions,  but  the  exophthalmos,  tremors  and  pur- 
poseless movements  are  not  present.  This  variety  often  disappears 
suddenly  when  menstruation  is  well  established. 

Symptomatology. — With  the  gradual  enlargement  of  the  lobes  of 
the  thyroid  there  may  be  noted  symptoms  resembling  chorea.  Nausea 
and  vomiting  at  the  sight  of  food  may  be  the  first  symptom  to  call 
attention  to  the  true  condition.  The  child  is  apt  to  be  irritable, 
easily  excited  and  depressed  if  left  without  companionship. 

Physical  examination  will  show  a  well-marked  tachycardia, 
usually  with  a  soft  systolic  murmur  at  the  base.  The  eye  later  has 
a  peculiar  fixed,  staring  look,  and  is  covered  by  the  upper  lid  with 
difficulty. 

Graefe's  sign,  or  the  difficulty  of  ra  sing  the  upper  eyelids  when 
the  child  is  asked  to  look  upward,  is  usually  observed.  Profuse 
diarrhea  which  is  controlled  with  difficulty  is  rather  frequent  in  early 
life.  The  sleep  is  disturbed,  and  several  times  during  the  day  the 
face  may  become  flushed  and  perspiration  appears  on  the  body. 

Course  and  Prognosis. — Rarely  the  course  is  very  rapid  and  ends 
fatally  in  a  few  weeks.  In  the  majority  of  cases  the  prognosis  is  slow, 
with  steady  emaciation  and  periods  of  remission.  The  younger  the 
patient  the  better  the  prognosis. 

Treatment. — Rest  in  bed,  both  physical  and  mental,  with  a  light 
milk  and  vegetable  diet  is  required  until  the  symptoms  subside. 
The  extremely  rapid  pulse  may  require  cardiac  sedatives.  Ice-cold 
applications  or  alcohol  compresses  may  answer.  If  not  sufficient  in 
effect,  the  tincture  of  strophanthus  or  digitalis  may  be  required.  The 
serum  of  Rogers  and  Beebe,  of  the  Cornell  laboratory,  has  proven  of 
value  in  selected  cases.  The  amount  injected  varies  with  the  degree 
of  toxicity  and  the  duration  of  the  disease.  Galvanization  with  a 
mild  current  of  three  milliamperes  may  be  used  with  advantage  in  con- 
junction with  any  form  of  treatment.  Thyroidectin,  a  product 
derived  from  the  blood  of  thyroidectomized  sheep,  is  sometimes  of 
distinct  value;  it  may  be  tried  and  continued  if  the  pulse  and  nervous 
symptoms  subside. 

Achondroplasia. 

Achondroplasia  (fetal  chondrodystrophy)  is  a  rare  affection  in- 
which  there  is  a  marked  disproportion  between  the  head  and  trunk  and 
extremities.  This  is  due  to  an  abnormal  process  of  endochondral 
ossification  at  the  junction  of  the  epiphysis  and  diaphysis.  The 
principal  change  is  a  defective  formation  of  rows  of  cartilage  cells 


DISEASES  OF  THE  DUCTLESS  GLANDS. 


423 


in  the  columnar  zone.  There  often  occurs  an  overgrowth  of  perios- 
teum in  this  region,  this  tissue  wedging  its  way  in  between  the 
epiphysis  and  diaphysis  from  the  periphery  toward  the  axis  of  the 
bone.     These  processes  both  prevent  growth  in  length  of  the  bone, 

Achrondroplasia  is  a  congenital  condition,  and  the  features  are 
evident  at  birth;  usually  the  parents  are  undersized  or  dwarfed. 

The  extremities  are  mostly  affected, 
leaving  the  head  and  trunk  nearly 
normal;  the  length  of  the  arms  and  the 
legs  is  greatly  diminished,  the  hands 
often  reaching  only  to  the  trochanters, 
while  normally  they  should  reach  to  the 
knees.  There  is  a  redundancy  of  tissues 
around  the  thighs,  making  thick  folds  in 
the  skin.  Muscular  tone  is  low  and  the 
joints  are  lax,  consequently  all  these 
children  are  late  in  walking.  The  head 
is  relatively  large,  the  bridge  of  the  nose 
is  usually  depressed,  the  tip  of  the  nose 
is  bulbous,  the  eyes  are  far  apart  and  in 
the  infant  the  tongue  may  be  thick,  this 
being  due  to  a  real  hyperplasia.  As  a 
rule,  the  fontanels  are  late  in  closing; 
teething  also  is  delayed. 

The  bones  are  short  and  thick  with 
enlarged  epiphyses;  curvature  in  the 
shaft  of  the  long  bones  which  often 
occurs  is  not  due  to  softening  but  to 
periosteal  intrusion  which  offers  resis- 
tance to  growth  in  length  of  the  dia- 
physes.  Frequently  a  marked  lumbar 
lordosis  is  present,  the  sacrum  being 
tilted  upward  and  backward.  Beading 
of  the  ribs,  as  in  rickets,  may  be  present. 

The  hands  are  small  and  square,  the  fingers  being  short  and  nearly 
equal  in  length  and  blunted  at  the  ends.  The  "trident  deformity" 
(divergence  of  middle  and  index-fingers  from  ring  and  little  fingers) 
is  often  noted.  The  mentality  in  these  children  is  not  affected  to  any 
marked  degree,  although  they  are  inclined  to  be  backward. 

Prognosis  as  to  life  is  good,  but  such  children  are  always  under- 
sized. Organic  extracts  from  the  thyroid  and  pituitary  glands  are 
used  in  the  treatment,  although  the  results  have  not  been  satisfactory 


Fig.  111. — Achondroplasia 
XBraiiford  and  Lovett). 


424  DISEASES  OF  CHILDREN. 

and  are  not  to  be  compared  in  any  sense  to  those  obtained  with  cretins. 
For  the  differential  diagnosis  see  the  article  on  Cretinism,  p.  426. 

Infantilism. 

This  is  a  condition  characterized  by  a  retardation  of  bodily  de- 
velopment out  of  all  proportion  to  the  chronological  age. 

These  children  are  always  small  in  stature,  underweight,  unde- 
veloped sexually,  and  retain  the  falsetto  voice  of  childhood.  Their 
mentality,  however,  is  usually  fair  and  they  are  capable  of  making  good 
progress  when  placed  in  school. 

Two  types  have  been  distinguished.  In  the  Brissaud  type 
the  children  are  somewhat  cretinoid  in  appearance,  the  face  being 
flat  and  chubby,  the  body  plump,  the  hair  sparse  and  fine  on  the  head, 
and  there  is  an  absence  of  pubic  hair.  In  this  type,  ossification  and 
epiphyseal  growth  may  be  delayed.  The  juvenile  state  of  the  body 
and  mind  is  long  retained. 

,  The  second,  or  Lorain  type,  is  distinguished  by  the  rather  slender 
body  and  finer  features,  although  the  genitals  and  voice  remain  long 
undeveloped.  The  mentality  is  apparently  unimpaired  in  this  latter 
type.  Herter  has  recently  pointed  out  that  in  cases  of  infantilism 
an  intestinal  digestive  disorder  may  be  the  etiological  factor.  He 
l^elieves  the  Bacillus  infantilis  to  have  a  direct  relation  to  the  disease. 

The  intestinal  bacteria  are  replaced  by  gram-positive  bacilli. 
The  maldevelopment  is  attributed  to  the  loss  of  fat  in  the  stools  and 
the  intolerance  to  carbohydrates. 

>.  The  cretinoid  type  reacts  favorably  for  a  short  time  to  the  use 
6i  thyroid  extract.  The  Lorain  type  is  not  affected  by  this  drug,  and 
^e  are  inclined  to  favor  Herter's  suggestion  to  treat  the  disease  as  a 
nutritional  disturbance.  >^- Gelatin  is  recommended  as  of  value.  Th'^ 
diagnosis,  however,  would  need  to  be  made  ver}-  early  in  order  to  obtain 
good  results. 

Cretinism. 

(Myxedema.) 

Myxedema  is  a  disorder  of  metabolism,  resulting  from  an  alteration 
or  absence  of  the  thyroid  body  or  its  functions. 

Cretinism. — Two  varieties  are  recognized:  The  endemic  and 
spoi'adic  (infantile  myxedema).  It  is  with  sporadic  cretinism  that 
we  are  concerned  in  this  country.  The  symptoms  are  the  result  of 
the  complete  absence  of  the  thyroid  gland. 

Etiology. — Hereditary  factors,  such  as  syphilis,  rickets,  and  tuber- 


DISEASES  OF  THE  DUCTLESS  GLANDS. 


425 


culosis  in  the  parents,  seem  to  favor  the  development  of  cretinism. 
The  disease  rarely  occurs  in  the  tropical  climates,  and  we  have  not  as 
yet  seen  a  colored  cretin. 

Symptomatology. — Sometimes  at  the  sixth  month,  or  soon  there- 
after, the  mental  dullness  of  the  child  is  noted.     It  shows  very  little,  if 


Fig.  112. 


-Hand  of  a  cretin,  showing  the  undeveloped  carpal 
bones  and  blunt  tinkers. 


aiiy,  interest  in  its  parents  or  surroundings.  Even  its  toys  are  unnoticed. 
Upon  inspection,  the  face  is  found  to  have  a  stupid,  vacant  expression, 
the  eyes  are  dull,  the  eye-lids  often  simulating  the  Mongolian  type  and 
are  wide  apart;  the  hair  is  sparse  and  coarse,  the  nose  flattened,  and 
the  bridge  sunken,  the  head  appears  large  and  is  set  upon  a  short 
thick  neck.  From  the  thick  lips  a  tongue  apparently  too  large  for 
the  mouth  protrudes,  and  saliva  drools  from  the  mouth.     The  general 


426  DISEASES  OF  CHILDREN. 

stature  is  quite  characteristic.  The  child  is  markedly  stunted,  the 
abdomen  appears  protuberant,  due  to  the  anteroposterior  curvature 
of  the  spine.  The  child  appears  well  nourished  or  even  obese.  An 
umbilical  hernia  is  quite  generally  present.  The  arms  and  legs  appear 
short  and  stumpy.  The  hands  are  spade-like  and  the  fingers  blunted; 
X-ray  examination  shows  characteristic  changes  in  the  carpal  bones. 
On  palpation  pads  of  subcutaneous  fat  may  be  felt  over  the  upper  part 
of  the  chest.  The  skin  is  found  to  be  harsh  and  dr3^  The  subcutan- 
eous fat  does  not  pit  on  pressure. 

The  fontanel  may  be  imperfectly  closed.  If  held  erect,  the 
peculiar  stature  and  prominent  abdomen  are  intensified.  The  head 
will  often  show  a  disproportion  from  the  normal,  as  will  the  length 
of  the  child  to  its  years  of  life  (see  Diagram  p.  31).  A  cretin  of 
eight  or  ten  years  may  simulate  in  height  a  child  of  two  or  three 
years.  The  temperature  is  usually  slightly  subnormal.  In  older 
children  a  history  will  be  elicited  of  marked  mental  deficiency.  The 
child  does  not  learn  to  speak,  often  showing  irritable  or  vicious  tem- 
per, with  uncleanly  habits  as  to  stooling  or  urination.  The  teeth  are 
very  apt  to  become  carious  soon  after  eruption,  and  stomatitis  is  fre- 
quently observed.  Untreated  cases  form  a  good  proportion  of  the 
so-called  dwarfs  scattered  throughout  the  country. 

The  blood  examination  shows  nothing  characteristic;  usually,  how- 
ever, there  is  a  diminution  of  the  red  blood-cells  and  hemoglobin.  The 
above  description  applies  to  the  typical  cretin;  however,  we  quite 
frequently  meet  cases  exhibiting  a  mental  deficiency  plus  some  of 
the  physical  characteristics  outlined  above,  but  in  a  milder  form. 
In  the  early  months  of  life  the  condition  often  goes  unrecognized 
because  the  physician  has  not  carefully  enough  observed  and  watched 
the  infant.  These  may  be  classed  as  cretinoids.  If  the  examiner  will 
keep  this  type  in  mind,  he  will  be  more  likely  to  diagnosticate  cases  in 
infancy. 

Differential  Diagnosis. — Mongolian  idiocy,  achondroplasia,  in- 
fantilism, rickets,  and  chronic  nephritis  must  be  differentiated  from 
sporadic  cretinism. 

The  Mongolian  idiot  is  small  in  stature  and  mentally  deficient, 
but  the  distinct  slanting  type  of  eyes  with  the  more  shapely  bodies  and 
their  willingness  to  go  about,  quite  readily  distinguish  them  from  the 
cretins. 

Achondroplasia. — The  large  heads,  the  very  short  arms  and  legs, 
which  are  in  marked  disproportion  to  the  normal  body  length,  added  to 
their  fairly  well  developed  intellect,  quite  readily  stamp  the  diagnosis. 

I nfatitilism.— The  symmetry  of  body  and  normal  mental  develop- 


DISEASES  OF  THE  DUCTLESS  GLANDS. 


427 


428 


DISEASES  OF  CHILDREN. 


ment  are  strong  distinguishing  characteristics.  However,  the  infantile 
voice  and  lack  of  genital  development  with  the  child-like  skin,  may 
occasionally  lead  to  a  mistaken  diagnosis  of  cretinism. 

Rickets. — This  condition  should  not  be  confounded,  as  in  rickets 
the  mentality  is  normal  and  the  bony  changes  are  quite  characteristic, 
even  when  the  child  is  dwarfed  by  its  deformities. 


Fig.  116. — Radiograph  of  arm  from 
Fig.  117,  showing  carpals. 


Fig.  117. — Cretin  with  acromegaly. 
Age  7  years,  untreated. 


In  chronic  nephritis  the  pitting  of  the  skin  and  the  examination 
of  the  urine  should  clear  up  a  suspicious  case. 

The  therapeutic  test  should  be  applied  whenever  there  is  any 
doubt. 

Prognosis. — The  importance  of  early  diagnosis  has  been  dwelt 
upon,  as  the  prognosis  is  so  much  better  the  earlier  the  treatment  is 


DISEASES  OF  THE  DUCTLESS  GLANDS. 


429 


instituted.  Up  to  the  age  of  puberty  comparatively  remarkable 
changes  result  from  treatment.  Young  adults  receive  only  very 
meager  benefit  from  the  treatment.  Untreated  cases  usually  suc- 
cumb to  some  intercurrent  infection  and  their  mentality  remains 
quite  stationary. 


Fig.  118. — Cretin,  before  treatment. 
{Dr.  Long's  case.) 


Fig.  119. — Same  case  after  one 
year  of  treatment. 


Treatment. — Desiccated  thyroid  extract,  if  fed  to  cretins,  soon 
produces  wonderful  changes  in  their  physical  and  mental  state. 
Thyroid  extract,  in  large  doses,  it  should  be  remembered,  has  a 
depressing  influence  on  the  heart  and  circulation  and  should  be 
carefully  given  if  there  is  any  cardiac  lesion.     It  should  be  given  in 


430  DISEASES  OF  CHILDREN. 

increasing  doses  to  infants,  beginning  with  one  grain  three  times  a 
day,  and  increased  slowly  to  five  grains  three  times  a  day.  Older 
children  may  finally  take  twenty  to  thirty  grains  in  a  day  if  necessary 
and  if  no  depressing  effect  is  produced.  (A  case  under  our  observation 
had  so  far  improved  as  to  locate  the  box  of  tablets  hidden  in  the  clock. 
He  ate  sixty  grains  in  all.  He  became  somewhat  cyanotic,  but 
quickly  revived  under  the  influence  of  stimulation.)  The  treatment 
must  be  continued  in  fairly  large  doses,  until  a  decided  change  has 
been  reached  and  further  improvement  does  not  take  place.  Then 
smaller  doses,  that  is,  about  ten  grains  a  week,  may  be  necessary 
throughout  life  to  prevent  a  relapse  into  the  former  condition.  The 
recession  of  the  tongue,  loss  of  adipose,  and  lack  of  drooling  are  the 
first  signs  of  successful  thyroid  therapy. 


SECTION  X. 
GENERAL  DISEASES  OF  NUTRITION. 


CHAPTER  XXXII. 

NUTRITIONAL  DISORDERS. 

Rachitis. 

(Rickets.) 

Rachitis  is  a  general  disorder  of  nutrition,  complex  in  character 
which  affects  the  growing  organism,  and  is  characterized  chiefly  by 
changes  in  the  bones,  ligaments  and  muscles  in  conjunction  with  ner- 
vous symptoms. 

Etiology. — Although  a  number  of  theories  have  been  advanced 
to  explain  the  causation  of  rickets,  none  have  displaced  the  generally 
accepted  idea  that  rickets  is  a  result  of  faulty  nutrition.  It  is  distinctly 
a  disease  of  infancy  and  childhood,  and  generally  a  preventable  one. 
It  seldom  occurs  before  the  sixth  month  of  life  (although  congenital 
rickets  is  not  unknown),  and  is  rarely  seen  after  the  third  year. 

In  this  country  it  is  more  commonly  seen  among  the  children  of 
foreigners,  especially  the  Italians  and  negroes.  While  it  is  undoubt- 
edly more  common  in  Europe  than  with  us,  still  the  number  of  cases 
seems  to  be  increasing  in  our  large  cities  where  the  hygienic  conditions 
are  poor.  It  is  most  frequently  seen  among  the  children  of  parents 
who,  themselves,  have  suffered  from  nutritional  disorders  or  who  have 
been  the  subjects  of  alcoholism  or  tuberculosis.  The  enfeebled  off- 
spring of  such  parents  are  particularly  liable  to  rickets  when  they  live 
in  badly  ventilated,  sunless  quarters  and  are  improperly  fed.  The 
food  may  cause  perversion  of  nutrition  because  it  is  deficient  in  certain 
elements,  as  the  proprietary  foods,  or  because  in  quantity  and  charac- 
ter it  overtaxes  the  digestive  functions.  It  is  rarely  seen  in  breast-fed 
children  unless  the  milk  is  deficient  because  of  prolonged  lactation, 
pregnancy,  or  disease.  The  proprietary  foods  and  condensed  milk, 
if  constantly  used  without  the  addition  of  fats,  are  particulary  liable 
to  cause  rickets.  Under  these  conditions  it  may  also  occur  among  the 
better  classes. 

Pathology. — The  greatest  changes  are  found  in  the  bones.  Clinical 
analysis  shows  that  the  bony  structures  in  rickets  are  made  up  of  two- 
thirds  organic  matter  instead  of  one-third,  as  found  in  normal  bones 
of  this  age.     A  cross  section  of  a  long  b'one  at  its  junction  with  the 

431 


432 


DISEASES  OF  CHILDREN. 


epiphysis  shows  an  enlargement  and  an  increase  in  the  cartilaginous 
structure  which  is  engorged  and  vascular.  The  periosteum  is  easily 
removed  and  the  medullary  portion  is  soft  and  traversed  with  trabeculsB. 
The  long  bones  may  be  soft  and  brittle  in  an  early  case,  but  in  cases 
of  long  standing  they  become  unusually  firm  and  hard.  In  the  bones 
of  the  skull  similar  periosteal  changes  occur  which  produce  abnormal 
ossification  and  calcification.     Many  of  the  ligaments  are  imperfectly 

developed  or  abnormally 
stretched.  The  spleen  is  en- 
larged in  about  10  per  cent,  of 
all  cases.  The  liver  and  tbe 
spleen  may  be  forced  down- 
ward by  thoracic  deformities. 

Symptomatology. — The  first 
evidences  of  rickets  may  escape 
attention  unless  the  examiner 
considers  the  possibility  after 
obtaining  the  history.  Among 
the  early  signs  are  fretfulness, 
disturbed  sleep  and  excessive 
perspiration  about  the  head, 
in  an  anemic  child.  It  is  not 
easily  comforted,  and  cries 
when  moved  as  a  result  of 
muscle  tenderness.  In  cases 
of  longer  standing,  physical 
examination  will  show  back- 
wardness in  development.  The 
infant  may  be  unable  to  hold 
up  its  head,  to  sit  up,  or  stand 
as  a  normal  child  at  the  same 
age.  The  muscles  are.  in  gen- 
eral, soft  and  flabby,  the  ab- 
domen is  distended  and  tym- 
panitic, and  evidences  of  im- 
perfect digestion  are  found  in 
the  fetid  stools  and  in  the  con- 
stipation alternating  with  an  occasional  diarrhea.  In  spite  of  this  tha 
appetite  is  generally  good,  more  food  being  taken  than  is  digested. 

In  more  advanced  cases  the  spleen  is  palpable,  and  the  anemia 
becomes  more  marked.  The  subjective  symptoms  above  recorded 
become  more  intensified,  and  changes  in  the  bony  skeleton  occur  which 


Fig.  120. — Extreme  rachitis,  showing 
marked  bony  deformities. 


NUTRITIONAL  DISORDERS 


433 


can  be  felt  on  palpation.  Among  these  the  beading  of  the  ribs  at  the 
costochondral  junctions  forming  the  so-called  rachitic  rosary  is  the 
most  characteristic.  In  infants  parchment-like  areas  in  the  occipital 
bones,  known  as  craniotabes,  is  a  finding  which  helps  to  establish 
the  diagnosis. 

At  the  junction  of  the  epiphysis  and  diathesis  nodular  bony  en- 
largements are  felt,  particularly  at  the  wrists,  ankles,  and  knees. 
The  forehead  is  marbled  with  enlarged  veins  and  in  shape  is  squared  in 


llMBIlfc: 

^  /*  ^  *^MftK^^^^^^^f 

Fig.  121. — Rachitis,  mild  form 
with  bow-legs. 


Fig.  122. — Rachitis,  showing 
pigeon-chest  deformity. 


front  and  flattened  on  top.  The  fontanels  are 
the  line  of  the  sutures  being  palpable.  Bosses 
center  of  the  parietal  bones  and  near  the  base  of 
At  this  stage  there  is  generally  an  evening  rise 
an  accelerated  pulse  rate.  The  body  weight  may 
the  increase  may  be  very  irregular.  Dentition 
process.  The  first  teeth  are  frequently  delayed, 
28 


late  in  closing,  even 
may  be  felt  in  the 
the  temporal  bones, 
of  temperature  and 
remain  stationary  or 
is  a  very  irregular 
sometimes  erupting 


434 


DISEASES  OF  CHILDREN. 


only  during  the  second  year,  and  then  with  much  discomfort.     They 
easily  decay,  sometimes  eroding  almost  to  the  gum. 

Nervous  Phenomena  often  develop  in  the  rachitic  infant.  Among 
these  the  most  characteristic  is  laryngismus  stridulus.  This  glottic 
spasm  may  occur  several  times  a  day  and  sometimes  results  in  carpo- 
pedal  spasms.  In  others  nystagmus,,  tetany,  or  inspiratory  crowing 
develops  from  the  nervous  instability.  Convulsions  are  not  uncom- 
mon and  recur  from  apparently  slight  causes. 

Deformities  occur  later  in  the  disease  as  a  result  of  the  softened 
condition  of  the  bones  and  the  relaxation  of  the  ligaments.  Be- 
sides the  deformity  of  the 
head,  the  thorax  shows 
marked  changes.  The  ra- 
chitic rosary  becomes  more 
marked,  due  to  a  sinking  in 
of  the  ribs  in  the  axillary  line 
and  a  flaring  out  of  the  ribs 
below. 

The  thorax  may  be  more 
or  less  funnel-shaped  and  ap- 
pear very  narrow  at  the 
clavicles,  due  to  the  abnor- 
mal flaring  below.  The 
sternum  may  be  drawn  in- 
ward or  pressed  forward, 
causing  the  pigeon-breast  de- 
formity. The  anteroposte 
rior  diameter  of  the  chest 
may  be  increased  while  the 
transverse  diameter  is  lessened.  Not  infrequently  a  well-developed 
groove  or  sulcus  is  formed  running  from  the  ensiform  on  either  side 
to  the  scapular  line.  This  is  known  as  Harrison's  groove,  and  results 
from  the  pull  of  the  diaphragm,  intrathoracic  pressure  and  the  ab- 
dominal distention.  These  thoracic  deformities  necessarily  affect  the 
organs  and  structures  within.  The  lungs  are  impeded  in  their  action, 
favoring  the  production  of  bronchitis,  pneumonia,  and  pulmonary 
collapse.  The  heart  action  and  circulation  may  be  impaired  with  a 
resulting  cyanosis.  Pneumonic  affections  are  peculiarly  resistant  tcT 
treatment,  and  their  chronicity  may  be  responsible  for  lymph-node 
enlargements  at  the  root  of  the  lung. 

The  bones  of  the  extremities  now  show  other  changes  besides  the 
epiphyseal  enlargements  at  the  wrists  and  lower  end  of  the  tibia, 


Fig.  123. — Knock-knees  in  a  rachitic  child. 


NUTRITIONAL  DISORDERS.  435 

which  occur  very  early  in  the  disease.  The  humerus  may  be  curved 
outward  while  the  legs  are  deformed  from  the  weight  put  upon  them 
in  efforts  to  stand  or  walk.  Bow-legs,  knock-knees,  and  deformities  of 
the  foot  are  thus  produced.  The  peculiar  sitting  posture  of  these 
children  sometimes  induces  curvature  of  the  femur. 

The  spine,  owing  to  the  relaxed  condition  of  the  ligaments,  bony 
changes,  and  deficient  muscular  power,  loses  its  normal  curves, 
eventually  becoming  bowed  from  the  cervical  region  to  the  pelvis. 
Lateral  curvatures  or  scoliosis  result  from  postural  positions  assumed 
while  being  carried  in  its  mother's  arms.  The  pelvis  may  suffer  with 
the  remainder  of  the  skeleton,  becoming  flattened  or  shortened  in  its 
anteroposterior  diameters. 

The  blood  shows  no  characteristic  changes.  Simple  anemia  is 
always  present.  The  hemoglobin  maj'  be  reduced  to  40  or  50  per 
cent.     A  moderate  leukocytosis  is  occasionally  obtained. 

Diagnosis. — There  is  no  difficulty  in  making  the  diagnosis  in  well 
advanced  cases.  In  the  early  stages,  pseudoparalysis,  sweating  of 
the  head,  anemia,  irregular  dentition,  and  a  distended  abdomen  in  a 
child  exhibiting  abnormal  nervous  symptoms  are  often  sufficient  to 
suggest  the  diagnosis. 

Infantile  paralysis  may  be  distinguished  by  the  electrical  reaction 
or  by  obtaining  mobility  in  the  prone  position  by  irritating  the 
plantar  surface  of  the  foot. 

In  hydrocephalus  there  is  a  true  enlargement,  in  place  of  an 
apparent  enlargement,  of  the  circumference  of  the  head,  with  a  bulging 
fontanel  (see  Fig.  143).  Syphilitic  affections  are  monoarticular, 
while  many  joints  are  simultaneously  affected  in  rickets. 

In  Pott's  disease  the  spinal  deformity  is  angular  and  rigid,  causing 
pain  when  attempts  at  motion  or  pressure  are  made. 

Course  and  Prognosis. — The  disease  itself,  while  chronic,  has  a 
tendency  to  recovery  when  changes  are  made  in  the  dietary  and 
surroundings  of  the  patient.  But  even  if  a  cure  results,  many  of  the 
bony  deformities  remain.  While  it  is  seldom  a  fatal  disease  it  m- 
fluences  the  mortality  in  early  life  because  of  the  lowered  resistance 
which  it  engenders.  These  children  more  readily  succumb  to  respira- 
tory, intestinal,  and  infectious  diseases.  Under  suitable  treatment 
the  disease  may  be  arrested  after  two  or  three  months,  and  further 
bony  changes  prevented.  Nervous  symptoms,  such  as  laryngismus 
stridulus,  are  very  promptly 'controlled  when  the  proper  treatment 
is  instituted. 

Treatment.  Prophylactic. — The  education  of  mothers  and  of 
school  girls  by  settlement  workers  in  matters  pertaining  to  the  feeding 


436  DISEASES  OF  CHILDREN. 

and  hygiene  of  infants  will  do  much  to  reduce  the  number  of  cases. 
Frequent  regulation  and  supervision  of  artificially-fed  babies  by  their 
physicians  would  prevent  overfeeding  with  too  strong  formulae  which 
so  often  occurs  among  the  more  intelligent  classes.  Examination  of 
the  breast  milk  in  children  who  are  not  sufficiently  developing  may 
show  a  marked  deficiency  in  the  proteins  or  fats.  Milk  of  this 
character  may  cause  the  development  of  rickets.  Mixed  feeding 
and  improvement  in  the  secretion  should  be  attempted  by  proper 
food. 

Dietetic  Treatment. — Dietetic  instruction  for  the  mother,  an  out- 
door life,  and  cleanliness  are  the  necessary  requirements  for  a  cure. 
The  food  in  the  case  of  an  infant  must  contain  a  sufficient  amount  of 
proteins.  If  the  feeding  has  been  on  condensed  milk  and  high  dilu- 
tion or  the  proprietary,  foods,  properly  modified  cow's  milk  will  in  a 
short  time  produce  a  marked  improvement.  The  modifications 
recommended  for  difficult  cases  of  infant  feeding  should  be  studied 
in  this  relation,  as  the  change  must  be  so  made  that  it  will  be  com- 
patible with  the  defective  assimilation  which  is  usually  present. 

Older  children  should  have  a  diet  list  especially  prepared  for 
them  which  may  contain  fresh  raw  milk,  yolk  of  eggs,  butter,  legumin- 
ous gruels,  and  vegetables  suitable  to  their  age. 

Hygienic  Treatment. — Provision  should  be  made  so  that  the 
child  may  live  as  much  as  possible  in  the  open  air.  In  bright  sunny 
weather  at  least  five  hours  a  day  should  be  spent  out  of  doors.  A 
roof  or  a  room  with  a  sunny  exposure  and  with  open  windows  may 
be  utilized  for  this  purpose.  Daily  baths  to  which  a  pound  of  sea 
salt  is  added  are  given,  unless  contraindicated  by  muscular  tender- 
ness. Mild  forms  of  massage,  breathing  exercises,  and  gymnastic 
treatment  given  in  the  second  year  of  life  are  productive  of  good 
results. 

Medication. — With  the  exception  of  cod-liver  oil  or  olive  oil, 
which  is  of  value  in  older  children,  drug  treatment  is  of  little  avail. 
Iron  and  arsenic  may  be  given  for  the  anemia  after  progress  has  been 
made  in  proper  food  assimilation.  If  phosphorus  is  administered, 
the  oil  or  the  elixir  may  be  used,  although  this  drug  and  the  lime 
salts  have  not  proven  of  any  benefit  in  our  experience. 

Deformities  of  the  long  bones  may  be  prevented  by  not  allowing 
the  child  to  assume  wrong  positions  and  not  encouraging  them  to 
stand  or  walk  until  the  softness  of  the  bones  is  overcome.  The 
rachitic  spine  is  corrected  by  keeping  the  child  in  the  horizontal  posi- 
tion in  bed  or  on  a  frame.  Surgical  measures  to  correct  bow  legs 
and  knock  knees  are  necessary  in  the  advanced  cases. 


NUTRITIONAL  DISORDERS.  437 

Congenital  Rachitis. 
(Antenatal  Rachitis.) 

Rarely  we  see  infants  born  with  well-marked  evidences  of  rickets. 
The  rachitic  fetus  develops  the  afifection  in  its  intrauterine  existence, 
probabl}'  during  the  placental  period  of  nutrition  (see  Fig.  25)  in 
consequence  of  disease  or  starvation  in  the  pregnant  mother.  The 
infant  is  born  with  changes  in  the  bony  skeleton  which,  although  not 
well-marked,  resemble  those  in  a  lesser  degree  found  later  in  rachitic 
infants.  Craniotabes,  enlarged  epiphyses,  and  beaded  ribs  may  be 
seen  and  palpated. 

Scorbutus. 
(Infantile  Scurvy;  Barlow's  Disease.) 

Scorbutus  is  a  constitutional  disease  due  to  a  prolonged  faulty 
diet  and  characterized  by  pain  and  swelling  in  the  extremities,  and 
hemorrhages  into  the  skin  and  mucous  membranes. 

Etiology. — Proprietary  infant  foods,  the  continued  use  of  steril- 
ized and  pasteurized  milk,  food  almost  exclusively  of  one  kind,  as 
condensed  milk  or  cereals  alone,  are  the  factors  which  produce  the 
necessary  predisposition  to  intestinal  putrefaction  and  toxemia,  and 
which  may  result  in  scurvy  after  some  weeks  or  months.  Although 
it  occurs  in  children  under  two  years  of  age,  the  latter  half  of  the  first 
year  shows  the  greatest  number  of  cases.  Malnutrition  from  food  not 
adequate  to  maintain  development  is  also  a  causative  factor  of  impor- 
tance. The  chemical  changes  brought  about  in  the  food  by  boiUng  or 
evaporation  in  dry  heat  for  the  purposes  of  preservation  are  essentially 
the  underlying  cause  of  the  disease.  The  cases  occur  more  frequently 
among  the  well-to-do  than  among  the  dispensary  cases,  as  the  latter 
cannot  afford  proprietary  foods,  and  much  sooner  give  a  mixed  diet. 

Pathology. — Subperiosteal  hemorrhages  occur  in  the  long  bones, 
especially  in  the  tibia  and  femur.  The  epiphyses  show  similar  changes, 
usually  in  proportion  to  the  involvement  of  the  periosteum  of  the 
shaft.  In  some  cases  the  periosteum  itself,  close  to  the  bone,  is 
infiltrated  and  thickened.  The  ribs  in  marked  cases  show  these 
changes  especially  on  their  margins.  The  spleen  may  be  found  en- 
larged and  hemorrhages  occur  in  the  pericardium,  pleura,  liver,  and  into 
the  muscles. 

Symptomatology.  Mild  Cases. — Attention  is  usually  first  at- 
tracted to  the  infant  because  it  cries  when  handled.  The  tenderness 
is  especially  marked  about  the  lower  extremities.     The  child  is  ex- 


438  DISEASES  OF  CHILDREN. 

tremely  fretful  and  usually  anemic.  It  is  not  uncommon  to  obtain  a 
history  of  some  fancied  injury  which  may  be  misleading.  The  infant 
will  hold  the  limbs  motionless,  usually  in  a  position  of  flexion,  and 
cries  or  screams  when  any  attempt  to  disturb  them  is  made.  In  some 
cases  only  one  extremity  may  at  first  be  tender.  No  fever  and  no 
swelling  may  be  present  at  this  stage  in  the  early  or  mild  types. 
Such  a  train  of  symptoms  when  present  in  conjunction  with  a  history 
of  prolonged  feeding  with  artificial  foods  which  lack  the  essential 
quality  of  freshness  should  be  suggestive  and  the  therapeutic  test 
applied. 

If  swellings  are  noted  over  the  epiphyses  in  one  or  both  extremi- 
ties, with  swelling  and  engorgement  of  the  gums,  the  diagnosis  is 
quite  certain. 

Aggravated  Cases. — In  these  unrecognized  or  neglected  cases, 
hematuria  may  be  the  first  symptom  for  which  the  child  is  brought  to 
the  physician,  or  it  may  have  been  treated  for  rheumatism  because 
of  the  swelling  and  pain  at  the  ankles.  Careful  examination  will  show 
spongy  gums,  bluish  in  color,  which  may  bleed  on  pressure.  If 
teeth  are  present  the  gums  override  them,  and  ulcerations  may  be  seen. 
Anemia  is  a  constant  symptom.  The  appetite  is  lost,  the  child  cries 
constantly  when  handled  and  blood  may  appear  in  the  stools.  In 
exceptional  cases  blood  is  effused  into  the  joints  and  the  epiphyses 
may  separate.  Ecchymotic  areas  appear  under  the  skin  especially 
over  the  swellings  on  the  lower  extremities,  but  may  also  appear  over 
the  ribs.  Concomitant  rachitic  changes  may  also  be  noted  due  to 
the  nutritional  faults.  About  the  orbit,  conjunctival  hemorrhages  may 
be  seen  or  even  protrusion  of  the  eye-ball.  The  face  is  usually  swollen, 
or  even  edematous.  Albumin  and  casts  are  sometimes  found  in  the 
urine. 

A  collective  investigation  by  the  American  Pediatric  Society 
gave  the  following  symptoms  in  their  order  of  frequency:  Pain  and 
tenderness  of  the  extremities,  sponginess  or  puffiness  of  the  gums, 
disability,  anemia,  cutaneous  hemorrhages,  hemorrhage  from  the 
rectum  and  hematuria. 

Diagnosis. — Infantile  scurvy  is  rarely  mistaken  by  those  who  are 
accustomed  to  obtain  a  good  history  and  who  make  a  systematic 
examination.  Traumatism,  acute  articular  rheumatism,  and  osteo- 
myelitis are  differentiated  by  the  swelling,  which  is  mainly  over  the- 
shaft  of  the  bone,  the  absence  of  temperature,  swollen  gums,  ecchy- 
moses  in  the  skin,  pseudoparalysis,  and  blood  in  the  urine  and  stools. 
A  radiograph  will  in  questionable  cases  complete  the  diagnosis. 

Course  and  Prognosis. — The  prognosis  is  very  good  when  the 


NUTRITIONAL  DISORDERS.  439 

disease  is  recognized  in  its  early  stages  and  prompt  treatment  insti- 
tuted. The  development  of  rickets  or  extreme  malnutrition  may 
delay  the  cure  in  aggravated  cases. 

The  great  majority,  even  the  neglected  cases,  recover  under 
antiscorbutic  treatment.  Beneficial  results  are  noted  after  a  few  days, 
the  mild  types  showing  remarkable  changes  within  a  fortnight. 

Treatment.  Prophylactic. — The  disease  can  be  prevented  by 
the  use  of  some  orange  juice  and  untreated  cow's  milk  in  the  dietary. 
Overanxious  mothers  should  be  warned  against  repasteurization  of 
their  infant's  milk  supply. 

Dietetic  Treatment. — The  food  should  be  abruptly  changed; 
fresh  raw  milk,  properly  modified  is  allowed.  Orange  juice,  one 
ounce  daily  in  divided  doses,  and  expressed  beef  juice  about  one  ounce 
during  the  day,  in  addition,  are  readily  taken.  Older  children  should 
be  given  mashed  potatoes  and  minced  vegetables,  such  as  carrots  or 
spinach.  The  limbs  are  encased  in  cotton  wool  and  supported  on  a 
pillow  until  the  tenderness  disappears.  Unnecessary  handling  should 
be  avoided.  Removal  to  the  outer  air  should  be  made  with  the  in- 
fant in  its  crib  or  on  a  pillow.  The  anemia  needs  no  drug  treatment 
as  it  disappears  under  the  dietetic  management  outlined  above. 

Marasmus. 

{Infantile  Atrophy;  Athrepsia.) 

Marasmus  is  a  very  common  functional  disorder  in  infancy, 
characterized  by  extreme  emaciation  resulting  from  inability  to 
assimilate  food. 

Etiology. — This  is  still  obscure.  It  is  usually  seen  in  the  first 
year  of  life.  The  greatest  number  of  cases  appear  in  institutions  and 
in  dispensary  practice.  Undoubtedly  food  poor  in  quality  and  given 
in  great  quantities,  coupled  with  unsanitary  surroundings,  have  a 
distinct  etiologic  bearing  on  the  development  of  marasmus.  If  the 
digestive  secretions  have  not  been  sufficiently  developed  by  proper 
food  or  if  they  have  been  overproduced  for  some  time  in  efforts  to 
digest  abnormal  food  constituents,  then  the  disorder  may  insidiously 
appear  with  symptoms  of  acid  intoxication. 

It  is  rarely  seen  among  breast-fed  infants  unless  there  is  a  marked 
perversion  of  the  supply. 

Pathology. — The  gross  lesions  found  in  even  a  well-marked  case  of 
marasmus  are  surprisingly  few.  Microscopically,  nothing  character- 
istic can  be  described.  The  body  is  devoid  of  adipose  tissue.  The 
muscles   are  soft,  pale,  and   thin.     The   overlying  skin  is   dry   and 


440 


DISEASES  OF  CHILDREN. 


wrinkled.  Hemorrhagic  areas  are  frequently  seen  beneath  the  skin 
and  sometimes  in  the  mucosa  of  the  gut.  The  lungs  are  frequently 
involved,  showing  either  hypostatic  pneumonia,  bronchopneumonia, 
or  atelectatic  areas.  We  have  found  these  often  in  combination. 
The  liver  is  somewhat  enlarged  and  fatty.  The  spleen  may  be  soft, 
but  is  not  enlarged.     The  kidneys  show  degenerative  changes  or  at 

least  a  cloudy  swelling.  The 
heart  is  small,  with  pale  muscle 
fibers.  The  mucous  membrane 
of  the  intestinal  tract  is  ex- 
tremely thin  and  pale.  The 
stomach  is  usually  dilated,  and 
its  lining  is  covered  with  ropy 
mucus.  The  agminate  and 
solitary  follicles  stand  out  more 
prominently  and  give  the 
"shaven  beard"  appearance. 
The  villi  are  not  easily  found, 
or  in  some  cases  are  entirely 
absent.  The  lymph  nodes  are 
enlarged.  In  some  cases  con- 
nective-tissue changes  take 
place  in  the  intestinal  mucosa 
in  isolated  patches. 

Symptomatology. — The 
train  of  symptoms  begins  in- 
sidiously. The  mother  usually 
brings  the  infant  because  she 
has  noted  emaciation  in  spite 
of  the  fact  that  the  food  has 
been  the  same  or  even  increased 
in  amount.  The  loss  of  weight, 
if  recorded,  is  found  to  be 
steady  but  constant.  The 
muscles  become  soft  and  flabby. 
The  skin  is  loose  and  wrinkled.  The  facial  appearance  changes,  due 
CO  the  loss  of  fat,  with  a  wrinkled  forehead  and  sunken  cheeks.  The 
fat  pads  over  the  buccinators  in  young  infants  remain,  however,  almost 
to  the  end.  The  abdomen  and  thighs  show  the  emaciation  quite 
early.  The  skin  feels  harsh  and  dry  and  has  lost  its  elasticity.  The 
muscle  tone  especially  over  the  abdomen  is  lacking.  The  emaciation 
progressing  further,  gives  an  "old  man"  expression  to  the  face.     This 


Fig.  124. — Marasmus. 


NUTRITIONAL  DISORDERS.  441 

outward  wasting  that  takes  place  corresponds  with  changes  in  the 
heart  muscle.  The  pulse  becomes  weak,  and  anemia  of  a  simple  kind 
is  present. 

A  striking  feature  is  the  insatiable  appetite.  The  infants  will 
take  an  enormous  quantity  of  food  and  still  cry  as  if  unsatisfied. 
The  stomach  dilates  and  vomiting  may  occur.  The  abdomen  is 
distended  with  gas,  and  the  liver  may  be  palpated  well  down  in  the 
abdomen.  The  stools  vary  considerably.  As  a  rule,  they  are  mixed 
in  color,  with  a  greenish-yellow  cast  predominating.  The}^  contain 
much  unchanged  food,  and  the  bulk  is  decidedly  increased.  The 
odor  is  musty  and  foul  and  almost  characteristic.  Diarrhoea  may 
follow  after  several  days  of  constipated  movements.  Erythemata 
in  the  napkin  region  devetop  and  persist.  The  temperature  is  rarely 
much  above  normal,  although  subnormal  readings  are  not  uncommon. 
The  thirst  in  some  cases  is  extreme;  the  infants  have  a  red,  dry,  and 
glazed  tongue.  A  finger  or  the  hand  is  sucked  continually,  which 
the  mother  attributes  to  hunger.  The  cry  is  a  low  moan  or  whine,  and 
is  not  repressed  when  attempts  at  comforting  the  baby  are  made.  In 
fact,  it  often  cries  more  when  disturbed.  As  the  disease  progresses 
the  emaciation  becomes  extreme;  the  child  resembling  a  living  skeleton. 
The  fontanel  and  eye-balls  are  sunken.  Excoriations  and  bed-sores 
develop  easily.  Stomatitis  is  not  infrequent.  Otitis  may  develop. 
The  breathing  becomes  shallow  and  feeble.  Pneumonia,  usually  of 
the  hypostatic  variety,  or  convulsions  frequently  bring  on  the  fatal 
termination. 

If  the  disease  is  arrested,  the  improvement  is  noted  first  in  the 
stationary  weight  and  improved  condition  of  the  stools.  Later  slight 
gains  are  made,  however,  with  frequent  discourag'ng  remissions. 
Finally  the  gain  is  steady,  but  slow. 

Course  and  Prognosis. — The  course  is  long  and  tedious,  and  even 
when  improvement  begins  months  are  needed  to  regain  a  normal 
appearance  and  development.  Unless  the  conditions  are  eminently 
favorable,  the  prognosis  is  extremely  poor,  the  infant  usually  dying 
of  some  intercurrent  disease. 

Treatment. — Since  the  disorder  is  the  result  of  defective  assimi- 
lation, and  artificial  feeding  being  at  best  the  introduction  of  a  foreign 
food,  a  good  wet  nurse  (see  p.  109)  should  be  secured  whenever  this 
is  at  all  feasible.  Maternal  milk  even  for  one  or  two  months  has  been 
sufficient  in  our  experience  to  turn  the  balance  from  inevitable  disaster 
to  beginning  success.  A  change  of  surroundings,  especially  in  the 
case  of  the  poor  infant,  is  the  next  consideration.  A  life  in  a  country 
district  with  plenty  of  fresh  air  and  sunshine  is  of  the  greatest  im- 


442  DISEASES  OF  CHILDREN. 

portance.  These 'infants  should  not  be  placed  or  taken  for  treatment 
in  hospitals  or  asylums.  Treatment  in  homes,  preferably  in  the  country, 
which  are  under  the  direct  supervision  of  a  physician,  is  much  more 
satisfactory.  The  Speedwell  Society,  at  Morristown,  N.  J.,  is  a  good 
example  of  the  best  method  of  dealing  with  these  cases.  If  the  child 
is  being  breast  fed  it  may  be  found  after  examination  that  the  char- 
acter of  the  secretion  may  be  improved,  and  meanwhile  mixed  feedings 
can  be  tried.  If  in  spite  of  this  no  gain  in  weight  is  made,  a  radical 
change  of  the  milk  must  be  made. 

If  artificial  feeding  must  be  resorted  to,  the  problem  is  a  very 
difficult  one  and  will  demand  a  knowledge  of  the  principles  of  infant 
feeding,  so  that  the  food  may  be  adapted  to  the  needs  of  the  case  at 
hand.  A  detailed  history  of  the  previous  feeding  is  essential,  and  it 
is  not  unusual  to  find  that  these  cases  have  gone  through  the  gamut 
of  almost  every  conceivable  food  in  an  effort  to  find  something  that 
will  agree  with  the  baby. 

Begin  the  dietetic  management  by  clearing  out  the  intestinal 
tract  with  calomel  or  castor  oil.  If  there  has  been  vomiting,  lavage 
is  indicated  once  a  day  for  two  or  three  days.  A  daily  irrigation  of  the 
bowels  with  saline  solution  for  the  first  week  is  rarely  amiss  (see 
pages  72  and  74). 

Feedings  should  be  small  in  quantity,  and  contain  at  first  protein 
and  fat  slightly  above  the  caloric  value  necessary  to  maintain  life. 
The  gruel  diluent  should  be  converted  by  a  diastatic  ferment,  and,  if 
necessary,  the  milk  may  be  peptonized.  It  is  a  good  rule  not  to  pre- 
scribe, no  matter  what  the  age,  greater  percentages  than  2  per  cent, 
fat,  6  per  cent,  sugar,  and  1  per  cent,  protein.  Not  infrequently  the 
marasmic  infant  does  not  do  well  on  any  ordinary  milk  modifications, 
because  the  infant  has  been  neglected  too  long  or  fed  upon  foods 
which  do  not  react  to  the  rennin  in  the  stomach.  Legume  gruels, 
one  to  two  ounces  of  the  flour  to  the  quart,  with  the  addition  of  one 
teaspoonful  of  pineapple  juice  to  each  four  ounces  of  feeding  is  given 
until  the  stools  change  in  character.  Whey  alternating  with  the  le- 
gume gruel  (see  section  on  Infant  Feeding)  is  then  cautiously  tried, 
and  as  soon  as  it  is  tolerated,  the  yolk  of  one  egg  rubbed  up  with  a 
quarter  of  a  teaspoonful  of  sugar  is  fed  daily  from  a  spoon.  Cream 
may  now  be  added  gradually  to  the  whey  and  this  mixture  may  en- 
tirely replace  the  gruel.  If  gain  in  weight  is  made  and  development 
progresses,  milk  and  gruel  mixtures  containing  1.5  per  cent,  of 
protein  with  the  addition  of  sodium  citrate,  one  grain  to  the 
ounce,  may  be  given  so  that  the  rennin  action  may  be  controlled. 
As  the  digestive  secretions  improve  the  infant  is  able  to  adapt  itself 


NUTRITIONAL  DISORDERS.  443 

better  to  the  fcrm  of  food  prescribed  and  in  this  resembles  again  the 
normal  baby. 

Progress  will  only  be  made  by  careful  attention  to  every  detail 
and  a  study  of  the  stools  before  making  any  advances  in  the  strength 
of  the  food.  The  fats  may  be  kept  low  with  advantage;  the  protein 
being  raised  if  the  dejecta  appear  to  warrant  it  until  a  satisfactory 
gain  in  weight  is  being  made. 

Medication  is  only  indicated  to  support  the  strength  until  the 
dietetic  measures  are  sufficiently  advanced  to  support  life.  For  this 
purpose  strychnin  is  valuable.  Alcohol  in  any  form,  if  given  for  any 
length  of  time,  does  more  harm  than  good.  Bismuth  is  occasionally 
necessary  to  allay  intestinal  irritation. 

Baths  are  decidedly  helpful  adjuncts  in  the  management.  Brine 
baths  are  especially  valuable.  They  are  given  warm  and  followed 
by  a  brisk  alcohol  rub  daily.  Asthenic  cases  may  at  first  need  sub- 
cuticular injections  of  normal  saline  solution,  or  the  use  of  sea 
water  as  advocated  by  Simon  may  be  tried. 

Diabetes  Mellitus. 

This  is  a  condition  of  persistent  glycosuria  rarely  seen  in  child- 
hood, and  differing  from  the  same  affection  in  adult  life  by  rapid  wasting 
and  a  speedy  fatal  ending. 

Etiology. — While  rarely,  if  ever,  seen  in  young  infants,  the  disease 
may  occur  in  children,  oftenest  between  the  ages  of  five  and  ten  years. 
Heredity  is  supposed  to  act  as  a  predisposing  cause,  and  a  diet  con- 
taining excessive  amounts  of  starch  and  sugar  may  have  a  causative 
influence.  The  real  cause  and  pathology  of  diabetes  mellitus  are  as 
obscure  and  uncertain  in  the  child  as  in  the  adult. 

Symptomatology. — Among  the  earliest  symptoms  noted  is  an  ex- 
cessive thirst.  A  child  who  has  been  previously  well-nourished,  besides 
drinking  great  quantities  of  water,  is  seen  to  be  listless  or  irritable, 
easily  tired  and  with  a  large  and  capricious  appetite.  Failure  of  nutri- 
tion and  strength  soon  follow,  and  in  a  short  time,  possibly  within  a 
few  weeks,  the  wasting  becomes  very  appreciable.  The  urine  is  passed 
frequently  and  in  large  amounts.  Several  quarts  may  be  voided  in  the 
twenty-four  hours.  The  specific  gravity  is  high,  as  in  older  subjects, 
and  large  quantities  of  sugar  and  occasionally  diacetic  acid  and  acetone 
may  be  found.  Nocturnal  incontinence  is  usually  present.  Irritation 
of  the  genital  organs  is  sometimes  caused  by  the  passage  of  the  sugar. 
The  skin  and  mucous  membranes  are  apt  to  be  dry,  and  the  former 
may  show  patches  of  eczema  and  occasionally  boils.     Itching  of  the 


444  DISEASES  OF  CHILDREN. 

skin  may  be  marked  and  annoying.  The  wasting  and  loss  of  strength 
proceed  with  great  rapidity  and  death  is  apt  to  ensue  from  exhaustion. 
In  some  cases  the  fatal  ending  is  due  to  an  intercurrent  pneumonia  and 
in  others  to  diabetic  coma.  The  disease  generally  runs  its  course 
within  a  few  months,  and  usually  under  six  months.  The  younger 
the  child  the  more  rapid  is  apt  to  be  the  course  of  the  disease. 

Prognosis. — We  have  never  seen  a  case  recover  in  a  young  child. 
In  any  given  case  of  glycosuria,  the  only  hope  is  that  the  condition 
is  temporary  and  due  to  an  excessive  ingestion  of  starches  and  sugars, 
the  so-called  alimentary  glycosuria.  There  will  then  be  an  absence 
of  wasting  and  the  other  symptoms  previously  noted. 

Treatment. — The  diet  must  consist,  as  far  as  possible,  of  milk, 
meats,  fats,  eggs,  and  green  vegetables.  Von  Noorden  recommends 
oatmeal  that  has  been  long  and  thoroughly  cooked,  which  then  ap- 
pears to  be  well-borne  by  diabetics  in  spite  of  its  starch,  and  he  thinks 
it  has  a  curative  tendency.  The  weakness  may  be  combated  with 
alcohol  and  strychnin.  Small  doses  of  morphin  and  codein  may  also 
be  tried. 


SECTION  XI. 
DISEASES  OF  THE  UROPOIETIC  SYSTEM. 


CHAPTER  XXXIIL 

DISORDERS  OF  THE  URINE  AND  KIDNEYS. 

The  Urine  in  Infancy. 

The  somewhat  vague  and  conflicting  reports  concerning  the  early 
secretion  of  urine  are  due  to  the  difficulty  of  collecting  it.  The  follow- 
ing methods  have  heretofore  been  relied  on:  Placing  a  small  sponge 
or  piece  of  absorbent  cotton  over  the  parts,  which  is  intended  to  be 
saturated  with  the  urine,  and  then  squeezed  out;  in  females,  fitting  a 
cup  or  wide-mouthed  bottle  or  pus  basin  under  the  vulva  to  be  held  in 
place  by  the  diaper;  in  males,  placing  a  bottle  or  condom  over  the  penis 
and  holding  it  in  position  by  straps  of  adhesive  plaster.  When  these 
methods  fail,  as  often  happens,  the  only  resort  left  has  been  the  cathe- 
ter, a  soft-rubber  catheter,  about  6  size,  being  best  to  employ.  In 
females,  where  the  greatest  difficulty  is  usually  encountered,  the 
employment  of  a  catheter  is  not  always  easy,  and  several  preliminary 
passages  into  the  vagina  often  occur  in  the  hands  of  the  inexperienced. 
To  obviate  these  difficulties  and  to  make  easy  and  safe  the  routine 
collection  of  the  infant's  urine  for  examination,  a  special  urinal  has 
been  devised.  It  consists  of  an  oval  opening  ending  in  a  funnel  that 
fits  into  the  collecting  vessel.  For 
efficiency  of  application,  two  sizes 
have  been  found  necessary.  No.  1 . 
(Small  size).  For  infants  under 
one   year.      No.    2.     (Large   size). 

For  infants  over  one  year. 

T^i  ,  1      1  •  I         Fig.  125. — Chapin's  infant  urinal. 

Place  the  large  openmg  around  ^ 

the  vulva  in  the  female  and  over  the  parts  in  the  male  with  the 

funnel  pointed  downward.     Put  tapes  through  the  openings  in  the 

arms   and   fix   by   tying  around  the  abdomen  and  both  groins.     To 

fix  more  firmly  in  place,  put  strips  of  plaster  over  the  arms.     Place 

the  end  of  the  funnel  in  the  collecting  bottle  which  is  kept  in  place 

by  the  diaper.     If  the  infant  is  very  restless,  put  a  cork  in  the  end  of 

the  funnel  and  dispense  with  the  bottle. 

It  was  hoped  that  this  apparatus  would  enable  one  to  collect  the 

full  amount  passed  in  twenty-four  hours,  but  this  has  not  proven 

445 


446 


DISEASES  OF  CHILDREN. 


feasible  without  constant  watching,  as  the  movements  of  the  baby 
make  a  small  leakage  unavoidable. 

Character  of  the  Urine. 

That  the  kidneys  functionate  before  birth  is  shown  by  the  blad- 
der usually  containing  urine  just  after  birth,  and  from  traces  of  this 
excretion  in  the  liquor  amnii.  The  kidneys  at  this  time  are  of  rela- 
tively large  size  and  more  distinctly  lobulated  than  in  later  life. 
There  is  a  great  discrepancy  among  the  various  writers  as  to  the 
amount  of  urine  passed  during  the*  early  days  of  life.  All  agree  that 
the  infant  passes  a  relatively  greater  amount  of  urine  than  the  adult. 
Parrot  and  Robin  state  that  the  new-born  passes  four  or  five  times 


Fig.  126. — Chapin's  infant  urinal  applied. 

more  urine,  per  kilogram  of  its  weight,  than  the  fully-grown  sub- 
ject. They  also  found  that  the  urine  at  this  time  has  always  about 
the  same  composition,  whether  passed  in  the  morning  or  evening. 
The  quantity  and  product  of  each  urination  varies  but  little  as  the  in- 
fant has  no  urine  of  sleep,  digestion,  etc.,  since  he  takes  an  identical 
food  and  at  nearly  the  same  intervals  of  time.  These  authors  found 
that  the  morning  voiding  varied  from  10  to  30  c.c.  Small  amounts 
may  be  voided  every  hour  through  the  day  and  several  times  at  night. 
There  seems  to  be  a  concensus  of  opinion  among  various  observers 
that  during  the  first  few  days  the  young  infant  excretes  about  from 
one  to  three  ounces  of  urine,  and  after  this  the  quantity  rapidly  in- 
creases.    At  the  end  of  the  first  week  there  mav  be  from   three  to 


DISORDERS  OF  THE  URINE  AND  KIDNEYS.  447 

twelve  ounces ;  at  six  months,  twelve  to  sixteen  ounces ;  at  one  and  two 
years,  from  sixteen  to  twenty  ounces;  from  two  to  five  years,  twenty 
to  thirty  ounces,  and  after  that,  approximating  the  adult.  It  must  be 
confessed  that  these  figures  are  general  and  tentative  and  seem  to  be 
a  fair  estimate  after  considering  many  conflicting  figures  of  the  various 
writers.  The  amount  will  vary  in  proportion  to  the  quantity  of  fluid 
given  as  well  as  the  action  of  the  bowels  and  skin. 

The  specific  gravity  is  low,  rarely  rising  above  1010  during  the 
first  six  months.  A  few  days  after  birth  and  until  the  end  of  the 
first  month  the  specific  gravity  is  very  low,  only  averaging  from  1003 
to  1004,  as  urea  and  inorganic  salts  are  not  found  in  large  quantity  at 
this  time.  It  then  increases  in  density,  but  it  is  not  apt  to  rise  much 
above  1010  until  after  the  tenth  year,  when  it  may  reach  as  high 
as  1020. 

The  first  urine  is  clear  colored,  although  it  is  sometimes  reddish 
from  an  excess  of  uric  acid  and  urates.  In  the  latter  case  it  may  be 
scanty  and  passed  by  drops  which  discolor  the  diaper.  The  uric  acid 
crystals  may  even  form  cencretions  in  the  pelvis  of  the  kidney.  In- 
fants seem  to  form  uric  acid  with  great  facility,  but  the  proportion 
of  uric  acid  to  urea  diminishes  later,  though  comparatively  large  all 
through  childhood.  In  proportion  to  the  body  weight  there  is  rela- 
tively less  urea  excreted  by  the  infant  than  by  the  child,  although 
the  latter  excretes  more  than  the  adult.  This  may  be  accounted  for 
by  the  active  metabolism  occurring  in  early  life. 

The  reaction  is  usually  neutral  or  faintly  acid.  In  the  cases  men- 
tioned where  large  amounts  of  uric  acid  are  formed  and  eliminated  dur- 
ing the  few  days  after  birth,  the  reaction  will  be  markedly  acid.  The 
reaction  may  be  at  times  slightly  alkaline  without  being  considered 
abnormal. 

The  question  as  to  the  presence  of  what  may  be  considered  patho- 
logical ingredients  at  this  time  and  their  significance  is  interesting,  but 
one  upon  which  various  writers  are  not  in  accord;  some  state  that  traces 
of  albumin  and  hyalin  casts  are  occasionally  found  during  the  first 
days  of  fife  and  with  little  significance.  According  to  Martin  Ruge, 
both  hyalin  and  granular  casts  may  be  found  in  the  urine  of  the 
newly-born.  Parrot  and  Robin,  on  the  contrary,  never  found  albu- 
min in  the  urine  of  healthy  new-born  infants,  nor  mucus  or  hyalin 
cylinders  as  in  normal  urine  of  the  adult.  Slight  glycosuria  has  occa- 
sionally been  reported  during  the  early  months,  especially  when  sugar 
has  been  too  freely  given  in  the  food.  All  through  infancy  traces  of 
indican  Avill  be  found  in  connection  with  gastrointestinal  irritation. 

During  the  early  years  of  life  slight  renal  hyperemia  appears  to 


448  DISEASES  OF  CHILDREN. 

be  very  easily  induced  and  to  be  coincident  to  almost  any  marked 
bodily  disturbance. 

The  rapid  metabolism  occurring  at  this  time  of  life  and  the 
vulnerability  of  the  kidneys  will  occur  to  everyone.  A  careful 
examination  of  the  urine  in  various  conditions  is  presented  in  the 
following  series  of  cases  from  the  babies'  wards  of  the  New  York 
Post-Graduate  Hospital.  The  first  series  includes  eighty-six  cases 
in  which  some  disturbance  of  the  gastrointestinal  tract  was  present. 
No  attempt  was  made  to  classify  these  cases,  and  they  include  simple 
indigestion,  fermentative  diarrheas,  intestinal  inflammation  and  ma- 
rasmus. In  a  large  number  the  condition  was  not  severe,  and  such 
cases  were  purposely  included  in  the  list.  Albumin  was  present  in 
seventy-five  cases  in  this  series  of  eight-six.  Its  presence  was  noted 
as  follows:  trace,  twenty-nine;  faint  trace,  thirty-one;  heavy  trace, 
fifteen.  Casts  were  present  in  thirty-seven  cases,  noted  as  hyalin, 
granular,  epithelial,  and  mucous.  There  were  sixteen  deaths  in  the 
series,  and  of  these  fourteen  had  albumin  present  and  ten  both  al- 
bumin and  casts.  In  thirty-two  cases  an  examination  for  indican 
was  made  and  found  present  in  twenty-two  of  the  cases.  The 
amount  was  estimated  as  follows:  trace,  four;  faint  trace,  one; 
heavy  trace,  seventeen. 

A  series  of  fifty-seven  cases  of  pulmonary  diseases,  such  as  severe 
bronchitis,  pleurisy,  and  pneumonia,  gave  the  following  results: 
forty-nine  had  albumin  in  the  urine,  thus  noted;  trace,  thirteen;  faint 
trace,  thirty;  heavy  trace,  six.  Thirty-two  cases  had  casts  present, 
either  hyalin,  granular,  epithelial,  or  mucous.  Of  the  seventeen 
deaths  in  this  series,  fifteen  had  albumin  present  and  ten  both  albumin 
and  casts.  An  examination  for  indican  in  twenty-three  specimens 
showed  its  presence  in  sixteen  cases.  Trace,  two;  faint  trace,  two; 
heavy  trace,  twelve. 

In  forty-five  cases  of  general  illness,  other  than  pulmonary  and 
gastrointestinal,  albumin  was  present  in  thrty-one  cases.  Trace,  nine; 
faint  trace,  eleven;  heavy  trace,  eleven. 

In  eleven  cases  of  cerebrospinal  meningitis,  nine  showed  heavy 
traces  of  albumin  and  casts. 

In  a  number  of  cases  of  cerebrospinal  meningitis,  with  coma,  a 
special  effort  was  made  to  collect  the  twenty-four  hours'  amount.  A 
baby  of  nineteen  months  passed  18  ounces,  one  of  two  years  passed 
16  ounces,  one  of  three  years  passed  16  ounces,  and  one  of  four  years 
passed  20  ounces.  ^411  of  these  specimens  had  traces  of  albumin  and 
casts,  and  the  urea  varied  from  1.7  to  2.7  per  cent. 

It  is  evident  that  any  disturbance  of  the  bodily  functions  during 


DISORDERS  OF  THE  URINE  AND  KIDNEYS.  449 

infancy  will  often  be  accomptlnied  by  the  presence  of  albumin  and 
casts  in  the  urine.  What  significance  does  this  condition  present  ? 
Can  actual  renal  disease  be  considered  to  exist  when  traces  of  albumin 
and  a  few  casts  are  found,  or  is  there  simply  an  irritation  of  the  renal 
tubules  accompanying  a  slight  congestion  and  having  no  special 
significance  ?  To  the  writer's  mind  a  study  of  the  cases  here  reported 
favor  the  latter  view.  Koplik,  in  a  study  of  twenty-five  consecutive 
cases  of  gastroenteritis,  found  that  all  but  four  showed  a  more  or  less 
severe  involvement  of  the  kidney.  In  all  of  these  cases  there  was 
albuminuria,  and  the  majority  of  them  showed  the  presence  of  casts. 
This  author  further  says  that  in  view  of  the  peculiar  physical  signs, 
and  the  rapid  improvement  of  an  almost  complete  suppression,  without 
leaving  behind  any  appreciable  lesion  of  the  kidney  as  evidenced  by 
albumin  or  casts  in  the  urine,  it  is  seen  we  are  not  dealing  with  a 
nephritis  in  the  ordinary,  but  in  a  special  sense.  As  in  these  cases  there 
is  usually  a  great  loss  of  fluid  from  the  system,  the  toxins  circulating 
in  the  different  organs  are  thus  placed  in  contact  with  the  delicate  cell 
structures  in  concentrated  form.  As  soon  as  the  water  taken  from 
the  system  is  partially  supplied,  these  poisons  are  washed  from  the 
organs,  and  the  latter  have  an  opportunity  to  resume  their  functions 
and  are  restored  to  normal.  The  moral  is  not  to  employ  irritating 
antiseptics  in  the  treatment  of  intestinal  diseases  and  to  give  a  full 
and  free  supply  of  water. 

It  would  seem  that  we  are  justified  in  concluding  that  the  urine 
of  infants  may  contain  traces  of  albumin  and  even  casts  without  any 
very  grave  results.  Even  when  actual  congestion  or  parenchymatous 
inflammation  exists  for  quite  a  long  time,  it  may  be  remembered  that 
in  early  age  the  kidney  possesses  a  wide  power  of  regeneration. 

The  exceedingly  fine  tests  now  often  employed  in  examining 
for  albumin  must  be  noted  as  one  explanation  of  its  frequent  discovery. 
As  small  amounts  of  nucleoproteid  are  always  present  in  urine,  prob- 
ably derived  from  the  disintegration  of  the  epithelial  cells  from  some 
part  of  the  urinary  tract,  such  as  the  ureter  or  bladder,  fine  traces 
of  albumin  may  come  from  such  a  source. 

Formation  of  the  Kidney. 

First  are  noted  two  minute  oval  structures  appearing  about  the 
seventh  week  of  fetal  life.  As  these  masses  develop  into  the  kidneys, 
they  assume  a  marked  lobulated  form,  and  this  structural  peculiarity 
persists  until  shortly  after  birth  when  this  distinctively  lobulated 
structure  disappears.  The  kidneys  are  relatively  larger  in  the  new- 
29 


450  DISEASES  OF  CHILDREN. 

born  than  in  older  subjects  and  are  placed  a  little  lower  down  in  the 
abdomen.  The  suprarenal  capsules  nearly  cover  the  kidneys  at  first 
and  are  relatively  large  all  through  childhood.  Malformations  have 
been  rarely  noted,  such  as  a  fusion  of  both  kidneys  into  an  irregular, 
horseshoe  mass.  Congenital  cystic  kidneys  have  been  occasionally 
reported  due  to  stenosis  of  the  pelvis,  ureters,  bladder  or  urethra,  fol- 
lowed by  a  dilatation  of  the  capsules  of  the  Malpighian  bodies  and 
of  the  tubules.  As  a  result,  the  kidneys  may  be  greatly  enlarged,  con- 
sisting of  a  mass  of  cysts.  A  few  cases  of  single  kidney,  supernumer- 
ary ureters,  and  other  rare  anomalies  have  been  reported  in  the 
literature  of  the  subject. 

Anuria. 

This  term  applies  to  a  cessation  of  the  urinary  secretion.  In  the 
newly-born  note  should  always  be  taken  of  the  first  passage  of  urine. 
Its  non-appearance  may  be  due  to  some  congenital  malformation  in 
any  part  of  the  urinary  tract.  Delay  in  voiding  at  this  time  is  most 
commonly  caused  by  uric  acid  infarction  in  the  kidneys.  The  highly 
acid  urine  may  then  pass  in  drops  which  dry  upon  the  diaper  and  the 
nurse  will  report  that  no  urine  is  being  passed.  Sometimes  a  reddish- 
brown,  brick-dust  discoloration  is  left  upon  the  diaper,  and  the  in- 
experienced will  think  that  the  infant  has  been  passing  bloody  urine. 
There  may  be  anuria  for  twenty-four  hours  from  this  cause  without 
the  infant  showing  any  constitutional  disturbance.  Examination 
will  usually  show  that  the  bladder  is  empty.  There  are  occasionally 
cases  in  young  infants  where  no  urine  is  passed  from  twelve  to  twenty- 
four  hours,  as  far  as  can  be  seen,  and,  as  long  as  there  is  no  apparent 
bodily  disturbance,  it  need  not  cause  undue  alarm.  In  older  children 
anuria  may  be  caused  by  various  drugs,  such  a  phosphorus  or  arsenic; 
by  nervous  disturbances,  as  from  fright,  hysteria,  etc.;  there  may  like- 
wise be  complete  suppression  in  the  course  of  acute  nephritis. 

Treatment.— Before  deciding  that  a  case  is  one  of  true  anuria, 
the  bladder  must  be  examined  to  be  sure  that  we  are  not  dealing  with 
ordinary  retention.  To  be  absolutely  sure  of  this,  it  may  sometimes 
be  necessary  to  pass  a  catheter.  A  soft-rubber  catheter,  about  6 
size,  is  best  employed  in  the  young  infant.  When  there  is  actually 
a  stoppage  of  the  urinary  excretion,  the  kidneys  may  be  stimulated  . 
into  action  by  slowly  injecting  into  the  bowel  large  quantities  of  warm 
normal  salt  solution.  Hot  fomentations  over  the  kidneys  may  like- 
wise be  tried.  The  best  diuretic  is  pure  water  given  frequently  and 
freely.     When  the   urine  is  scanty  and  very  acid,  the  young  infant 


DISORDERS  OF  THE  URINE  AND  KIDNEYS.  451 

may  be  given  from  one  to  three  grains  of  citrate  or  acetate  of  potash 
every  two  or  three  hours  in  a  tablespoonful  of  watef.  One  or  two 
drops  of  sweet  spirits  of  niter  may  be  combined  with  the  alkali  or  given 
alone  to  favor  diuretic  action. 


Polyuria. 

A  temporary  increase  in  the  amount  of  urine  excreted  may  be 
caused  by  the  administration  of  large  quantities  of  fluid,  such  as  milk 
or  water,  by  irritation  of  the  base  of  the  brain,  by  hysteria,  by  the 
cirrhotic  form  of  nephritis,  or  by  diuretics.  As  a  rule,  the  condition 
is  due  rather  to  functional  than  organic  disturbance. 

Diabetes  Insipidus. 

When  polyuria  assumes  a  chronic  form  and  there  is  a  daily  ex- 
cretion of  large  quantities  of  pale-colored  urine  having  a  very  low 
specific  gravity,  the  condition  is  known  as  diabetes  insipidus.  The 
real  pathology  of  this  disease  is  not  understood,  but  the  prevailing 
opinion  is  that  it  owes  its  inception  to  some  sort  of  neurosis.  The 
causes  are  obscure,  but  cases  have  been  reported  where  heredity 
seemed  to  be  a  factor  and  others  seem  to  be  coincident  to  injuries  of 
the  brain  induced  by  falls  or  blows,  and  to  the  various  forms  of  menin- 
gitis. The  disease  begins  early  in  life,  the  majority  of  the  cases  reported 
being  under  ten  years.  An  evacuation  of  very  large  quantities  of 
watery-looking  urine  is  characteristic  of  the  disease,  even  as  much  as 
ten  quarts  may  be  passed  daily.  The  specific  gravity  is  very  low, 
varying  from  1001  to  1005,  and  the  urine  contains  neither  albumin 
nor  grape  sugar.  Urination  is  frequent  and  may  reach  a  condition  of 
incontinence.  There  is  great  thirst  and  the  patients  drink  very  large 
amounts  of  water  to  make  up  for  the  constant  loss.  The  loss  of  fluid 
sometimes  induces  a  condition  of  dryness  of  the  skin  and  mucous 
membranes  with  diminished  glandular  secretion.  Palpitation  of  the 
heart,  neuralgia,  and  headache  may  occasionally  be  present,  and  vaso- 
motor disturbances,  such  as  flushing  of  the  face.  When  the  disease 
has  lasted  a  long  time  the  general  nutrition  is  apt  to  suffer  and  the 
bodily  resistance  is  lowered.  In  many  cases,  however,  the  appetite 
is  good  and  the  general  health  does  not  seem  to  be  affected.  While 
occasionally  a  case  may  recover  spontaneously,  the  disease  is  usually 
chronic,  lasting  many  years,  and  death  finally  ensues  from  some  inter- 
current disease.  The  diagnosis  is  made  by  noting  the  continual 
passing  of  very  large  quantities  of  pale  urine  with  low  specific  gravity, 


452  DISEASES  OF  CHILDREN. 

but  without  grape  sugar,  albumin  or  casts  of  any  kind.     Excessive 
thirst  is  likewise  always  present. 

Treatment. — The  best  results  will  be  attained  by  hygienic  meas- 
ures. The  diet  must  be  carefully  regulated,  only  easily  digested  articles 
being  allowed.  The  ingestion  of  fluids  may  be  moderately  restricted. 
Warm  clothing  with  a  free,  out-of-door  life  and  a  pleasurable  amount  of 
exercise  are  valuable  hygienic  agencies.  Drugs  have  little  effect  upon 
the  course  of  the  disease.  The  following  have  been  recommended: 
atropin  or  belladonna,  antipyrin,  the  various  bromids,  ergot,  and 
arsenic. 

Renal  Calculi. 

Uric  acid  infarctions  often  are  found  in  newly-born  infants. 
They  consist  usually  of  uric  acid  or  urates  deposited  in  the  straight 
tubes.  The  calices  and  pelvis  of  the  kidneys  may  at  the  same  time 
contain  small  masses  of  uric  acid  or  the  urates  of  ammonium  and 
sodium.  These  concretions  should  disappear  by  the  end  of  the  first 
or  second  week.  They  are  caused  by  the  abundant  excretion  of  uric 
acid  during  the  first  days  with  an  insufficient  supply  of  water  to  hold 
the  salts  in  solution.  As  noted  in  another  section,  the  urine  may  be 
passed  in  drops  leaving  a  dark  red  stain  upon  the  napkin,  or  there 
may  even  be  temporary  anuria  in  this  condition.  A  true  renal  lesion 
is  not  apt  to  follow.  A  free  administration  of  water  will  generally 
induce  a  solution  and  washing  out  of  these  deposits.  Small  calculi 
sometimes  persist  in  the  pelvis  of  the  kidney  or  they  may  be  formed 
later  by  the  deposition  of  uric  acid  or  the  urates.  When  the  calculi 
are  not  dissolved  they  may  be  washed  down  into  the  ureter  and  pro- 
duce the  symptoms  of  true  renal  colic.  There  is  then  acute  pain  in 
the  region  of  the  kidney  radiating  downward,  with  possibly  even 
retraction  of  the  testicle  on  the  affected  side.  Small  amounts  of  urine 
are  frequently  passed  which  may  be  tinged  with  blood.  In  older 
children  there  may  be  vomiting  and  marked  evidences  of  prostration. 
When  the  calculi  reach  the  bladder  the  pain  quickly  ceases.  Pro- 
longed acts  of  screaming  on  the  part  of  infants,  otherwise  unaccounted 
for,  are  doubtless  often  due  to  the  passage  of  small  crystals  of  uric 
acid  through  the  ureter.  The  only  way  to  be  positive,  however,  is  to 
examine  the  urine  when  voided  for  the  presence  of  these  crystals. 
Occasionally,  but  rarely,  a  good-sized  calculus  may  become  impacted 
in  the  urethra.  Examination  may  be  made  for  this  condition  in 
cases  of  anuria,  and  evidences  of  local  discomfort  will  be  a  guide  for 
the  search.     The  irritation  of  pelvic  calculi  may  sometimes  induce  a 


DISORDERS  OF  THE  URINE  AND  KIDNEYS.  453 

mild  form  of  pyelitis.  Where  a  large  calculus  becomes  firmly 
wedged  in  the  ureter  it  may  produce  a  complete  stoppage  which  will 
eventuate  in  hydronephrosis. 

Treatment. — Young  infants  should  be  given  water  as  a  routine 
measure,  from  a  teaspoonful  at  first  to  half  an  ounce  later,  several 
times  daily,  in  order  to  keep  the  uric  acid  and  urates  in  solution  and 
flush  out  the  kidneys  and  urinary  tract.  When  the  urine  becomes 
scanty  and  high-colored  the  water  may  be  given  even  oftener,  and 
one  or  two  grains  of  citrate  or  acetate  of  potash  added  every  three 
hours  will  form  a  good  alkaline  water.  Older  children  must  have 
their  diet  carefully  regulated  and  fluids  freely  given.  The  indications 
for  surgical  interference  are  the  same  as  in  adults. 

Hematuria. 

The  red  blood-corpuscles  may  be  present  in  the  urine  either  from 
certain  general  disturbances  of  the  body  or  from  local  causes  in  the 
genitourinary  tract.  As  an  example  of  the  first  may  be  cited  infec- 
tious diseases,  such  as  variola,  scarlet  fever,  or  severe  paludism;  various 
blood  diseases  of  obscure  origin,  such  as  hemophilia  and  purpura; 
scorbutus  and  large  doses  of  irritating  drugs,  such  as  chlorate  of 
potassium.  Among  local  causes  may  be  mentioned  acute  nephritis, 
new  growths  in  the  kidney  or  bladder,  and  calculi  in  the  kidney,  ureter, 
bladder,  or  urethra.  Some  help  may  be  had  in  discovering  the  source 
of  the  bleeding  by  noting  the  condition  of  the  urine  as  passed.  If  the 
blood  is  thoroughly  mixed  with  the  urine  at  this  time,  the  source  is 
apt  to  be  in  the  kidney.  Where  the  bladder  is  the  seat  of  the  hemor- 
rhage, the  blood  is  usually  passed  at  the  end  of  urination,  while  if  the 
urethra  is  affected,  the  first  urine  passed  contains  the  blood.  Small 
amounts  of  blood  in  urine  may  give  it  a  slightly  reddish  or  smoky 
appearance,  while  large  quantities  may  appear  as  clots.  In  any 
uncertain  case  the  microscope  must  be  depended  on  for  the  diagnosis. 

Treatment.— This  must  be  directed  to  the  cause,  but  small  doses 
of  the  fluid  extract  of  ergot  may  be  frequently  given  if  the  bleeding 
continues. 

Hemoglobinuria. 

Hemoglobin  may  be  present  in  the  urine  with  very  few  or  no 
blood-cells.  It  is  occasionally  seen  in  the  same  infectious  diseases 
that  may  produce  hematuria;  also  from  irritating  drugs  that  are 
eliminated  by  the  urinary  organs  as  carbolic  acid  and  chlorate  of 


454  DISEASES  OF  CHILDREN. 

potassium.  It  is  also  rarely  seen  in  an  epidemic  form,  occurring  in 
the  newly-born,  known  as  Winckel's  disease.  The  diagnosis  is 
made  by  the  microscope  which  shows  the  blood  pigment  granules, 
but  not  the  red  cells  themselves. 

Functional  Albuminuria. 

{Cyclic  or  Physiologic  Albuminuria.) 

An  occasional  albuminuria,  without  casts  or  other  evidences  of 
kidney  disease,  may  be  noted  in  children.  It  is  more  apt  to  occur 
shortly  before  or  during  adolescence.  The  cyclic  form  is  apt  to  exhibit 
itself  in  the  urine  passed  during  the  day,  while  the  patient  is  on  his 
feet,  but  disappears  during  the  night  and  early  morning.  This  is 
explained  by  posture,  as  there  is  no  albumin  present  when  the  patient 
is  lying  down,  but  appears  after  the  erect  posture  is  maintained.  Cold 
bathing,  overexercise,  too  large  i"njestion  of  protein  food,  and  various 
forms  of  indigestion  and  malassimilation  have  all  been  advanced  to 
explain  transient  albuminuria.  There  are  usually  no  symptoms,  and 
the  patient  may  even  show  all  the  signs  of  apparently  perfect  heath. 
There  is  frequently  the  same  uncertainty  and  obscurity  in  this  con- 
dition in  childhood  as  in  later  life.  The  cases  should  be  kept  under 
observation  and  if  albumin  persists  very  long,  even  in  small  amounts, 
there  is  probably  some  lesion  in  the  kidneys.  The  condition  of  the 
heart  and  the  tension  of  the  pulse  must  be  watched,  as  beginning 
hypertrophy  and  constant  high  tension  point  to  kidney  tBOuble.  While 
being  observed,  the  diet  should  be  carefully  regulated,  overfatigue 
prevented,  and  attention  given  to  general  hygiene  rather  than  to 
measures  directed  to  the  kidneys. 

Indicanuria. 

Indican  in  minute  traces  may  be  found  in  normal  urine,  but  the 
condition  may  be  considered  abnormal  when  a  marked  reaction  is 
given  to  the  test.  It  is  usually  seen  in  the  various  forms  of  intestinal 
indigestion  and  fermentation.  The  putrefaction  of  proteins  under 
the  action  of  various  bacteria  results  in  a  substance  known  as  indol 
from  which  the  indican  is  derived.  The  condition  is  sometimes 
also  noted  in  tuberculosis,  empyema  and  various  diseases  accompanied 
by  suppuration.  The  treatment  is  dietetic  and  directed  against  the 
various  forms  of  intestinal  disturbance  that  are  accompanied  by 
undue  food  decomposition  within  the  intestine.  The  color  scheme  and 
test  for  indican  are  given  in  the  section  on  Special  Tests  (p.  53). 


DISORDERS  OF  THE  URINE  AND  KIDNEYS.  455 

Acetonuria  and  Diacetonuria. 

Minute  traces  of  acetone  and  diacetic  acid  may  be  found  in 
normal  urine.  They  may  be  increased  in  fevers  and  in  any  condition 
accompanied  by  undue  protein  decomposition.  Tliey  have  been 
found  in  cases  of  diabetes  followed  by  coma. 

Congestion  of  the  Kidney. 

As  the  kidneys  functionate  very  actively  in  early  life,  various 
grades  of  hyperemia  may  be  easily  induced.  The  various  infectious 
conditions,  marked  digestive  disturbances,  high  fevers  from  any  cause, 
irritating  drugs,  and  exposure  to  cold  may  be  accompanied  by  traces 
of  albumin  and  tube  casts  in  the  urine.  This  does  not  necessarily 
mean  that  there  is  the  beginning  of  an  acute  nephritis,  as  the 
condition  may  pass  away  with  the  subsidence  of  the  cause  of  the  irri- 
tation. If  the  latter  persists  too  long,  however,  actual  nephritis 
may  ensue.  In  a  previous  section,  evidence  was  shown  that  almost 
any  marked  bodily  disturbance,  especially  in  infancy,  will  often  be 
accompanied  by  the  presence  of  albumin  and  casts  in  the  urine.  This 
may  be  simply  an  evidence  of  irritation  of  the  tubules  accompany- 
ing a  slight  congestion.  The  urine  may  be  scanty,  but  if  there  is 
nothing  beyond  congestion,  even  if  extreme  and  followed  by  almost 
complete  suppression,  there  will  be  a  rapid  improvement  without  leav- 
ing behind  any  appreciable  lesion  of  the  kidney.  A  congested  kidney 
is  apt  to  be  somewhat  enlarged  as  there  is  more  blood  in  the  vessels 
than  normal,  and  if  the  condition  has  lasted  for  several  days  the  cortex 
may  be  very  red  and  have  the  gross  appearance  of  cloudy  swelling. 

The  treatment  includes  keeping  the  bowels  free  and  giving 
plenty  of  pure  water.  The  latter  is  especially  important  in  condi- 
tions accompanied  by  a  great  loss  of  fluid  when  the  toxins  circulating 
in  the  d  fferent  organs  in  concentrated  form  irritate  the  delicate  cell 
structures  of  the  kidney  as  of  the  other  vital  organs,  and  hence  need 
dilution  and  washing  out  from  the  system.  The  skin  must  be  kept 
warm  and  moist  and  hot  fomentations  over  the  kidneys  sometimes 
appear  to  do  good.     A  milk  diet  is  best. 

Chronic  Congestion. 
(Passive  Hyperemia  of  the  Kidney.) 

Chronic  lesions  of  the  heart  or  lungs  or  any  pressure  effect  that 
interferes  with  the  general  circulation,  and  thus  with  the  kidney 
circulation,  may  result  in  chronic  congestion.     It  occurs  principally 


456  DISEASES  OF  CHILDREN. 

in  older  children.  A  long-continued  impeded  circulation  through  the 
kidney  will  be  followed  by  enlargement  of  the  organ  caused  by  a  dis- 
tention of  the  vessels  with  blood.  On  section,  a  dark-red  color  is 
noted.  The  urine  is  passed  in  small  amounts,  with  high  specific 
gravit}^,  and  usually  showing  albumin  and  tube  casts. 

The  treatment  must  be  directed  to  the  skin  and  bowels,  with  the 
use  of  various  diuretics,  all  of  which  are  noted  in  our  consideration 
of  the  treatment  of  nephritis.  The  principal  treatment  must  naturally 
be  aimed  at  the  original  condition  that  results  in  keeping  up  the  con- 
gestion. 

Nephritis. 

In  attempting  to  classify  the  various  forms  of  nephritis  from  the 
standpoint  of  morbid  anatomy,  the  student  at  the  bedside  will  be 
much  confused.  It  is  often  impossible  to  diagnosticate  the  anatomical 
varieties  of  nephritis  by  either  a  study  of  the  clinical  symptoms  or  of 
the  urine.  The  physician  frequently  cannot  tell  whether  he  is  dealing 
with  acute  congestion,  acute  degeneration,  or  acute  glomerulonephritis 
of  a  mild  type.  From  the  standpoint  of  treatment,  it  is  not  very 
important  to  attempt  to  sharply  differentiate  these  various  disturb- 
ances. Nephritis  will  be  here  considered  only  as  acute  or  chronic, 
although  the  synonyms  will  show  the  lesions  that  may  preponderate 
in  each  condition  as  far  as  the  epithelial,  interstitial  or  vascular  tissues 
of  the  kidney  are  concerned. 

Acute  Nephritis. 

(Acute  Parenchymatous  Nephritis;  Acute  Exudative  Nephritis; 
Acute  Desquamative  Nephritis;  Acute  Tubular  Nephritis;  Acute 
Glomerulonephritis;  Acute  Diffuse  Nephritis;  Acute  BrighVs 
Disease.) 

Definition. — An  acute  inflammation  involving  any  or  all  (diffuse) 
of  the  histological  structures  of  the  kidney. 

Etiology. — Acute  nephritis  commonly  occurs  as  a  secondary  con- 
dition in  the  course  of  the  specific  infectious  diseases.  Scarlet  fever 
and  diphtheria  most  frequently  induce  nephritis,  but  variola,  varicella, 
measles,  meningitis,  typhoid  fever,  and  influenza  may  also  be  noted 
as  not  infrequent  causes.  Any  severe  disease,  such  as  pneumonia  or 
acute  enteritis,  may  irritate  the  kidney  to  the  point  of  inflammation 
in  striving  to  eliminate  noxious  products.  Thus  the  colon  bacillus 
may  b3  the  irritating  agent.     Cases  that  are  considered  primary  are 


DISORDERS  OF  THE  URIXE  AND  KIDNEYS.  457 

doubtless  usually  due  to  some  infection  that  is  obscure  as  to  its  point 
of  entrance.  The  kidney  lesions  may  be  started  by  the  toxins  gen- 
erated by  infectious  bacteria  or  may  be  caused  by  the  direct  action 
of  the  organisms  themselves,  in  which  case  the  disease  assumes  a  severe 
type.  Exposure  to  cold  and  wet  may  cause  nephritis,  possibly  by 
checking  the  action  of  the  skin  and  thereby  throwing  extra  work 
upon  the  kidneys,  or  possibly  by  lowering  the  vitality  so  that  various 
bacteria  will  grow  sufficiently  to  infect  the  body,  as  in  tonsillitis.  The 
continued  ingestion  of  drugs  irritating  to  the  kidney,  especially 
chlorate  of  posash  or  the  carbolic  acid  series,  may  induce   nephritis. 

Pathology. — The  kidneys  are  usually  congested,  soft  and  some- 
what enlarged,  the  cortex  being  swollen  and  presenting  the  appear- 
ance of  cloudy  swelling.  The  pyramids  generally  appear  congested. 
In  other  cases  the  kidney  shows  little  apparent  change  to  the  naked 
eye.  Under  the  microscope,  changes  may  be  noted  in  the  epithelial, 
interstitial  or  vascular  tissues.  The  various  names  have  been  given  to 
the  nephritis  according  to  the  tissue  that  is  preponderatingly  affected 
by  the  inflammation.  When  the  glomerular  lesions  are  most  marked, 
it  may  be  called  glomerulonephritis;  if  the  glandular,  epithelial  cells 
in  the  tubules  are  mostly  affected,  we  have  parenchymatous  nephritis; 
if  the  stroma  is  principally  affected,  it  is  named  interstitial  nephritis. 
When  all  the  anatomical  structures  of  the  kidney  are  markedly  in- 
volved, it  is  called  diffuse  nephritis.  The  renal  cells  of  the  tubules, 
as  seen  under  the  microscope,  show  cloudy  swelling,  degeneration  and 
sometimes  desquamation.  The  tubules  may  be  filled  with  casts. 
In  the  glomerular  type,  the  cells  covering  the  capillary  tufts  undergo 
swelling  and  proliferation.  The  cells  making  up  the  capsules  of  the 
Malpighian  bodies  may  likewise  undergo  proliferation.  There  may  be 
an  infiltration  of  the  stroma,  with  leukocytes  and  plasma  cells  and  a 
production  of  new  connective-tissue  cells.  The  blood-vessels  of  the 
affected  part  are  engorged,  and  there  may  be  a  proliferation  of  the 
cells  of  the  capillaries. 

Symptomatology. — In  early  life,  nephritis  most  frequently  occurs 
as  a  secondary  condition  in  the  infectious  diseases,  especially  in 
scarlet  fever.  It  may  come  during  the  height  of  the  primary  disease 
or  when  the  latter  is  subsiding.  In  scarlet  fever  it  is  more  apt  to 
ensue  during  the  period  of  desquamation  in  the  third  and  fourth  week. 
The  urine  becomes  scanty  with  a  reddish-brown,  smoky  discoloration 
from  the  presence  of  red  blood-cells  or  hemoglobin.  Albuminuria  is 
present,  usually  in  marked  degree;  it  may  be  so  extreme  as  to  change 
the  urine  into  a  solid  on  boiling.  The  urea  is  onh'  partly  excreted  by 
the  crippled  kidneys,  and  hence  accumulates  in  the  blood.    The  amount 


458 


DISEASES  OF  CHILDREN. 


of  urea  daily  found  in  the  urine  is  thus  below  normal.  The  specific 
gravity  may  be  diminished,  but  when  the  urine  is  loaded  with  albumin 
it  usually  is  as  high  or  higher  than  in  normal  urine.  Epithelial, 
granular  and  hyalin  casts  are  usually  found  in  abundance.  Renal 
epithelial  cells,  red  blood-corpuscles  and  leukocytes  are  also  present. 
The  temperature  in  nephritis  is  not  apt  to  be  very  high,  perhaps 
averaging  from  101°  to  102°  F.;  if  it  goes  much  higher— such  as  104° 

to  105°  F. — it  shows  a  severe 
type  of  the  disease.  The  ner- 
vous symptoms  vary  with  the 
severity  of  the  attack.  In  mild 
cases  there  may  be  only  apathy 
or  restlessness  and  slight  head- 
ache; in  severer  cases  there  is 
worse  headache,  dimness  of  sight, 
stupor,  coma,  or  convulsions. 
A  high  tension  pulse  usually 
precedes  the  symptoms  of  ure- 
mia. The  graver  nervous  symp- 
toms usually  come  in  connection 
with  scanty  or  suppressed  urine 
and  they  disappear  as  the  secre- 
tion becomes  more  abundant, 
with  a  lessening  of  the  amount 
of  blood,  albumin  and  casts,  and 
a  freer  elimination  of  urea.  The 
cerebral  symptoms  may  be 
caused  by  a  general  edema  of 
the  brain  or  by  a  compression  of 
Fig.  127.-Puffiness  of  the  face  and  edema  ^j^at  Organ  bv  an  effusion  of 
of  the  extremities  in  a  case  of  acute  nephritis.  °  "     ' 

serum     within     the    ventricles. 

The  principal  gastroenteric  symptom  is  vomiting,  without  much  or  any 
nausea,  and  occasionally  diarrhea  is  seen  in  the  uremic  state.  More  or 
less  dropsy,  due  to  a  transudation  of  serum  caused  by  the  altered  con- 
dition of  the  blood,  is  one  of  the  commonest  symptoms  of  the  disease. 
It  usually  begins  as  a  slight  anasarca  of  the  feet  and  ankles  from 
whence  it  may  extend  up  the  legs  to  the  scrotum  and  finally  to  the 
trunk.  An  effusion  of  serum  in  and  around  the  internal  organs  with 
grave  results  may  take  place  in  the  following  usual  order  of  frequency 
— edema  of  the  lungs,  effusion  into  the  pleural  and  peritoneal  cavities, 
into  the  pericardial  sac,  into  the  brain  and  finally  into  the  loose  con- 
nective tissue  of  the  larynx  producing  that  alarming  and  fatal  con- 


DISORDERS  OF  THE  URINE  AND  KIDNEYS.  459 

dition,  edema  of  the  glattis.  The  anasarca  is  apt  to  precede  these 
internal  effusions  but  this  is  not  invariably  the  case.  It  is  evident 
that  dropsy  as  a  symptom  may  induce  little  or  no  discomfort  to  the 
patient  or  seriously  threaten  his  life  according  to  the  part  of  the  body 
affected.  The  types  of  nephritis  seen  in  different  infectious  diseases 
show  some  difference  as  far  as  the  symptom  dropsy  is  concerned. 
Thus  in  scarlet  fever  there  is  early  seen  a  puffiness  under  the  eyes  and 
a  swelling  of  the  limbs,  while  in  diphtheria  it  is  rare  to  see  any  anasarca, 
even  with  a  severe  nephritis. 

The  nephritis  rarely  seen  in  infants  and  young  children,  inde- 
pendently of  the  acute  exanthemata,  is  sometimes  called  the  primary 
form.  This  means  only  that  the  exact  source  of  the  agent  that  infects 
the  kidneys  is  unknown.  It  may  come  from  the  tonsils  or  gastro- 
enteric tract.  Doubtless  the  colon  bacillus  is  frequently  responsible. 
The  few  cases  reported  in  infancy  have  usually  shown  an  abrupt  onset, 
high  fever,  vomiting,  and  sometimes  diarrhea  and  a  high  mortality. 
In  older  children,  the  onset  and  course  are  less  severe  and  the  prog- 
nosis better.  Dropsy  is  reported  as  uncommon  in  both  varieties  in 
so-called  primary  nephritis. 

The  average  duration  of  acute  nephritis  is  from  one  to  three 
weeks.  The  improvement  in  symptoms,  and  clearing  up  of  the  urine 
is  gradual.  Nephritis  is  usually  accompanied  and  followed  by  marked 
pallor  and  anemia.  While  there  is  always  diminution  in  the  amount 
of  urine,  complete  suppression  is  comparatively  rare.  The  latter  may 
exist  for  many  consecutive  hours  and  yet  be  followed  by  recovery. 
An  examination  of  the  bladder  must  always  be  made  to  be  sure  that 
retention  is  not  interpreted  to  mean  suppression. 

Complications. — The  most  frequent  complications  are  referable 
to  the  heart  and  lungs — in  the  former,  endocarditis  and  pericarditis; 
in  the  latter,  pneumonia  and  pleurisy.  In  rare  instances  meningitis 
may  supervene. 

Diagnosis. — The  recognition  of  the  disease  must  rest  principally 
on  careful  examinations  of  the  urine.  It  may  be  suspected  when 
moderate  fever  and  pallor  exist  without  apparent  cause. 

Prognosis.— The  younger  the  child,  the  worse  the  prognosis. 
After  three  or  four  years  of  age  the  prospect  of  recovery  is  good,  espe- 
cially if  a  fair  amount  of  urine  is  passed  and  there  are  no  marked  evi- 
dences of  uremia.  If,  however,  there  is  a  large  number  of  casts  pres- 
ent with  a  tendency  to  suppression,  the  outlook  is  graver.  The 
mere  amount  of  albumin  passed  is  not  of  so  much  prognostic  value. 
While  a  majority  of  the  cases  undergo  complete  recovery,  there  is 
always  the  possibility  of  chronic  nephritis  supervening.     This  must 


460  DISEASES  OF  CHILDREN. 

be  borne  in  mind  in  giving  the  ultimate  prognosis  and  the  urine  should 
be  examined  at  intervals  for  a  long  time  so  that  such  a  condition  may 
be  early  recognized.  Children  may  have  a  subacute  or  chronic  nephri- 
tis with  very  few  symptoms,  and  hence  the  condition  may  be  overlooked 
during  a  long  period  of  apparent  health,  or  until  an  acute  exacerbation 
brings  on  a  serious  or  fatal  result. 

Treatment. — Children  suffering  from  infectious  diseases,  especially 
scarlet  fever,  should  be  handled  carefully  as  far  as  the  organs  of  elimi- 
nation are  concerned — particularly  the  bowels  and  the  skin.  In  this 
way  the  kidneys  will  be  saved  some  of  the  irritation  induced  by  the 
effort  to  eliminate  the  toxins  produced  by  the  original  disease.  Rest 
in  bed,  keeping  the  skin  warm,  and  the  use  of  mild  saline  laxatives, 
with  milk  and  farinaceous  foods  will  usually  be  sufficient  for  this  pur- 
pose. When  nephritis  supervenes,  in  spite  of  such  care,  more  active 
measures  must  be  employed.  These  resolve  themselves  into  a  freer 
use  of  cathartics,  diuretics  and  diaphoretics,  with  a  fluid,  unstimulating 
diet.  The  action  of  cathartics  is  usually  more  certain  than  other 
agencies.  Calomel  in  doses  of  one  or  two  grains  is  a  good  cathartic  and 
diuretic  as  well.  Citrate  of  magnesia,  a  few  ounces  at  a  dose,  and 
compound  jalap  powder,  ten  grains  to  a  child  of  five  years,  given 
every  few  hours,  will  prove  helpful  in  relieving  the  kidneys  through 
the  bowels.  Unstimulating  diuretics,  such  as  the  citrate  and  acetate 
of  potash,  from  two  to  five  grains  every  two  or  three  hours,  are  valu- 
able remedies.  A  teaspoonful  of  cream  of  tartar  to  a  glass  of  water, 
drunk  freely  from  time  to  time,  is  a  pleasant  diuretic.  Sweet  spirit 
of  niter,  from  5  to  20  drops,  according  to  age,  well  diluted,  occasionally 
does  well.  Plain  water,  given  freely,  is  one  of  the  most  constant  and 
valuable  diuretics  we  possess.  It  should  always  be  frequently  given 
in  cases  of  illness  of  all  kinds  in  children  to  insure  a  free  action  of  the 
kidneys.  The  alkaline  effervescing  waters,  such  as  vichy,  will  some- 
times be  taken  in  preference  to  plain  water.  Most  of  the  diuretic 
remedies  have  diaphoretic  effect  when  the  skin  is  kept  warm,  while 
if  the  surface  is  cool  the  latter  is  lost  and  the  result  will  be  exclusively 
diuretic.  In  urgent  cases,  the  muriate  of  pilocarpin  will  often  have 
a  most  beneficial  effect  in  producing  free  sweating  and  hence  in  reliev- 
ing the  engorged  kidneys.  To  a  child  of  three  years,  gr.  gV  or  even 
^V  of  a  grain  may  be  given  every  five  or  six  hours  until  results  are 
obtained.  It  may  be  given  hypodermatically  if  a  quick  effect  is  de- 
sired, but,  as  it  is  depressing,  stimulants  must  be  given  at  the  same 
time.  The  infusion  of  digitalis  has  a  diuretic  as  well  as  stimulating 
effect,  but  it  sometimes  tends  to  upset  the  stomach. 

The  hot  pack  affords  one  of  the  most  convenient  and  efficient. 


DISORDERS    OF  THE  URINE  AND  KIDNEYS.  461 

methods  of  acting  on  the  skin.  A  blanket  is  soaked  in  hot  water  (110° 
to  115°  F.)  wrung  out  and  packed  around  the  patient's  body.  Hot- 
water  bottles  are  put  in  position  and  the  whole  is  surrounded  by  a 
dry  blanket.  The  skin  is  soon  bathed  in  a  profuse  perspiration, 
aud  this  may  be  repeated  several  times  in  the  day  if  necessary. 
Hot  saline  injections  (105°  F.)  given  with  a  fountain  syringe 
and  soft  catheter,  or  a  double  current  tube,  have  a  very 
beneficial  effect  in  favoring  kidney  action.  One  or  two  quarts 
may  be  thus  employed  several  times  a  day.  If  there  is  a 
pulse  of  high  tension  and  nervous  symptoms  pointing  to  eclampsia, 
nitroglycerin,  and  small  doses  of  morphin  may  do  good.  At  five 
years,  grains  ^^^  to  ^^jj  of  nitroglycerin  may  be  given  every  two  or 
three  hours.  During  convalescence,  some  preparation  of  iron  should 
be  given  for  the  anemia  that  always  ensues.  The  diet  all  through 
the  disease  must  consist  principally  of  milk  given  freely.  Some  of 
the  variations  of  milk  often  do  better  than  whole  milk.  Thus  skim 
milk,  buttermilk,  milk  and  vichy,  kumyss,  junket,  and  whey  may  be 
tried.  The  various  farinaceous  foods  mixed  with  milk  are  also  desir- 
able as  nourishment. 


Chronic  Nephritis. 

(Chronic  Diffuse  Nephritis;  Chronic  Parenchymatous  Nephritis;  Large 
White  Kidney;  Amyloid  or  Waxy  Kidney;  Chronic  Interstitial 
Nephritis.) 

Definition. — A  chronic  inflammation  involving  any  or  all  of  the 
histological  structures  of  the  kidney,  but  usually  either  prevailingly 
parenchymatous  or  interstitial,  especially  the  former. 

Etiology. — It  usually  occurs  as  a  sequel  to  one  of  the  acute  infec- 
tions, but  with  especial  frequency  after  scarlet  fever.  The  interstitial 
variety  is  usually  seen  in  older  children  in  connection  with  hereditary 
syphilis.  Valvular  disease  of  the  heart,  alcoholism,  and  chronic 
tuberculosis  may  also  be  noted  as  causes.  Prolonged  suppuration, 
especially  of  bones  or  joints,  is  usually  responsible  for  the  waxy  form. 

Pathology. — In  the  parenchymatous  form,  sometimes  known  as 
the  large,  white  kidney,  the  organ  is  generally  enlarged,  with  a  yellow- 
ish-white appearance  on  section.  The  renal  epithelial  cells  present  a 
swollen,  granular,  or  fatty  appearance.  The  tubules  may  be  con- 
tracted or  dilated,  and  are  usually  filled  with  casts.  There  is  com- 
pression of  the  tufts  in  the  glomeruli  from  proliferation  of  the  cells 


462  DISEASES  OF  CHILDREN. 

of  the  capsule  and  increase  of  connective  tissue.  The  waxy  kidney 
is  usually  much  enlarged  and  presents  the  mahogany-brown  dis- 
coloration with  iodin.  This  form  of  degeneration  is  marked  in  the 
capillaries  of  the  tufts  and  in  the  smaller  arteries  of  the  kidney.  In  the 
interstitial  form,  the  kidney  is  small,  with  adherent  capsule  and 
nodular  surface.  The  new  connective  tissue  is  distributed  through 
the  kidney  in  an  irregular  manner,  producing  a  twisting  or  atrophy  or 
dilatation  of  the  tubules,  the  latter  sometimes  forming  cysts.  The 
glomeruli  may  likewise  be  enlarged  or  atrophied  into  little  fibrous 
specks.  There  is  thinning  of  the  cortex  after  the  chronic  inter- 
stitial change  has  become  marked. 

Symptomatology. — The  symptoms  and  course  of  chronic  nephritis 
in  the  child  do  not  differ  in  any  essential  way  from  the  clinical  mani- 
festations seen  in  the  adult,  especially  as  the  disease  is  usually  found 
in  later  childhood.  In  mild  cases,  there  may  be  only  general  weari- 
ness, occasional  vomiting  and  digestive  disturbances,  headache,  and 
anemia.  In  severer  cases,  dropsy  is  a  very  constant  symptom. 
The  edema  may  be  limited  to  the  lower  extremities  and  the  vulva  or 
scrotum,  or  there  may  likewise  be  effusion  into  the  interior  cavities, 
more  often  into  the  peritoneal  cavity  and  occasionally  into  the  pleura 
and  pericardium.  The  dropsy  is  variable,  sometimes  being  excessive 
and  then  suddenly  clearing  up  for  a  time.  Albumin  is  pretty  constantly 
present  in  the  urine,  with  hyalin,  granular,  and  fatty  casts.  These 
abnormal  ingredients  vary  in  amount  with  the  increase  or  decrease 
in  the  severity  of  the  disease.  The  daily  quantity  of  urine  passed 
likewise  varies  from  much  below  normal  to  about  the  proper  amount. 
The  progress  of  the  disease  is  usually  slow  and  very  irregular,  perhaps 
continuing  for  a  number  of  years  with  occasional  exacerbations  when 
the  symptoms  become  urgent,  followed  by  periods  of  remission  when 
the  patient  is  comfortable.  Eventually,  death  takes  place  from 
uremia  or  some  intercurrent  disease.  In  the  chronic  interstitial  form, 
edema  is  rare,  but  there  is  the  usual  high  tension  pulse  and  enlarge- 
ment of  the  left  ventricle.  As  in  adults,  the  nervous  disturbances 
preponderate,  such  as  headache,  neuralgia,  spasmodic  dyspnea,  poor 
vision,  and  dyspeptic  troubles.  The  urine  is  passed  in  large  amounts, 
having  a  low  specific  gravity  and  frequently  without  albumin.  Casts 
are  not  nearly  so  abundant  as  in  the  other  and  more  common  form 
of  chronic  nephritis. 

Complications. — Edema  of  the  lungs  and  pneumonia  may  be 
considered  the  most  frequent  complications.  One  may  also  look 
for  pleurisy  or  endo-  or  pericarditis. 

Diagnosis. — The  most  objective  symptoms  leading  to  a  recognition 


DISORDERS  OF  THE  URINE  AND  KIDNEYS.  463 

of  this  condition  are  a  marked  lessening  in  tiie  quantity  of  urine  passed 
and  some  form  of  dropsy.  Poor  nutrition,  pallor,  headache,  high 
arterial  tension  and  an  enlarged  heart  should  lead  to  careful  exami- 
nations of  the  urine  upon  which  the  diagnosis  must  ultimately  rest. 

Prognosis. — Complete  recovery  is  rare.  The  symptoms,  however, 
may  rest  in  abeyance  for  long  intervals  of  time.  The  disease  may  last 
for  three  or  four  years  and  the  patient  eventually  succumb  to  some  inter- 
current trouble.  The  immediate  prognosis  becomes  bad  in  the  pres- 
ence of  very  scanty  urine  and  extensive  dropsy. 

Treatment. — The  management  of  the  case  must  be  largely  hygienic 
and  dietetic.  The  skin  must  be  kept  warm  by  flannels  and,  if  possibe, 
the  patient  sent  to  a  warm,  dry  climate.  Sudden  changes,  with  marked 
lowering  of  the  temperature,  are  liable  to  be  dangerous.  If  dropsy 
is  present  the  cathartics,  diuretics,  and  diaphoretics  used  in  acute  neph- 
ritis may  be  employed.  The  same  is  true  of  uremic  symptoms. 
General  tonics,  and  especially  iron,  may  be  constantly  given.  While 
a  fluid  diet,  principally  milk,  is  the  mainstay,  it  is  sometimes  necessary 
to  allow  a  more  generous  diet,  especially  when  anemia  is  extreme. 
The  farinaceous  foods  can  always  be  given,  and  it  is  sometimes  an  ad- 
vantage to  give  meat  in  moderation.  If  weakness  is  great,  one  must 
not  persist  on  a  too  low  protein  diet. 


Pyelitis. 

Definition. — An  inflammation  of  the  lining  membrane  of  the  pelvis 
of  the  kidnej^,  often  associated  with  nephritis  or  cystitis. 

Etiology. — Congenital  malformations  of  the  kidney  or  ureter  may 
cause  p3'elitis,  also  tuberculosis  of  the  kidney  and  renal  calculi.  There 
may  be  an  infectious  form  of  pyelitis  in  connection  with  such  infec- 
tious diseases  as  typhoid  fever,  scarlet  fever,  or  diphtheria.  Cases 
have  been  reported  as  caused  by  the  common  colon  bacillus.  There 
may  be  an  extension  of  inflammation  from  neighboring  structures, 
such  as  the  kidney  or  bladder.  Finally,  general  pyemia  may  be  re- 
sponsible for  the  disease. 

Pathology. — The  p3'elitis  accompanying  a  general  infection  usu- 
ally attacks  both  kidneys,  while  a  purely  local  irritation  involves  only 
one  side.  The  inflammation  involves  the  mucous  membrane  of  the 
pelvis  and  is  of  an  acute  inflammatory  nature  with  congestion  and 
infiltration  of  the  cells  and  occasionally  punctate  hemorrhages.  Pus  is 
formed  and  passes  out  with  the  urine.  It  may  quickly  collect  in 
such  an  amount  as  to  distend  the  pelvis  and  calices  of  the  kidney. 


464  DISEASES  OF  CHILDREN. 

thus  leading  to  pyonephrosis.  A  pyelitis  that  persists  is  accompanied 
by  more  or  less  nephritis. 

Symptomatology. — These  are  somewhat  irregular  in  character. 
Pain  may  be  a  prominent  symptom,  especially  noted  during  urination. 
In  other  cases  there  is  no  evidence  of  local  discomfort  and  not  much 
besides  pyuria  to  indicate  the  disease.  A  moderate,  continuous  fever 
may  be  present  or,  perhaps  more  often,  the  temperature  assumes  an 
intermittent  character  and  may  be  accompanied  by  chills  and  sweat- 
ing. In  all  cases  of  unexplained  fever  in  early  life  with  cachexia,  this 
disease  may  be  suspected  and  the  urine  carefully  examined.  The  urine 
is  turbid,  with  an  acid  reaction,  and  contains  blood-  and  pus-cells  and 
epithelial  cells  desquamated  from  the  pelvis  of  the  kidney.  Albumin 
is  present,  sometimes  from  the  pus  and  at  other  times  as  an  evidence 
of  accompanying  nephritis,  when  epithelial,  granular,  or  hyalin  casts 
are  also  found.  The  urine  is  usually  swarming  with  bacteria.  If  the 
pyelitis  is  of  tuberculous  origin,  tubercle  bacilli  will  be  present  in  the 
urine.  Occasionally  large  quantities  of  pus  will  be  discharged  into  the 
urine  from  an  abscess  rupturing  into  the  pelvis  of  the  kidney.  If  the 
disease  becomes  chronic,  pyuria  may  be  the  only  constant  symptom  to 
be  noted.  There  is  also  apt  to  be  evidences  of  failure  of  health  and 
emaciation  in  these  cases.  An  examination  of  the  blood  in  pyelitis 
usually  reveals  a  leukocytosis. 

Diagnosis. — This  rests  finally  on  an  examination  of  the  urine, 
which,  when  acid  and  containing  pus  and  pelvic  epithelium,  will  make 
the  diagnosis  positive.  Cystitis  is  rare  in  children,  but  examination 
for  urethritis  in  the  male  and  vulvovaginitis  in  the  female  must  be 
made  when  pus  is  found  in  the  urine.  The  acid  reaction,  however,  in- 
dicates pyelitis.  Pain  in  the  region  of  the  kidneys,  irregular  fever 
with  chills  and  scanty  urine  point  to  pyelitis,  but  pyuria  is  the  only 
constant  and  positive  symptom. 

Prognosis. — The  prognosis  is  good  when  the  kidney  proper  has 
not  become  much  involved  in  the  inflammation.  Where  there  is 
extensive  nephritis  from  calculi  or  pyonephrosis  ensues,  the  prog- 
nosis is  bad. 

Treatment. — A  free  administration  of  water  to  which  citrate  or 
acetate  of  potash  has  been  added  will  serve  to  flush  out  the  kidney 
and  che^k  the  acidity  of  the  urine.  Two  to  five  grains  of  these  alkalies 
may  be  given  every  three  hours.  Urotropin,  in  doses  of  one  to  two 
grains,  three  times  a  day,  to  a  three-year  old  child,  is  an  efficient 
urinary  antiseptic.  If  calculi  are  present  and  can  be  located,  sur- 
gical treatment  may  give  relief.  The  same  may  be  true  of  pyo- 
nephrosis. 


DISORDERS  OF  THE  URINE  AND  KIDNEYS.  465 

Perinephritis. 

Definition. — An  inflammation  of  the  loose  connective  tissue 
around  the  kidney. 

Etiology. — The  inflammation  may  be  primary  and  due  to  trauma 
or  possibly  to  cold  and  exposure;  and  secondary  to  suppurating  foci 
within  the  kidney,  such  as  may  be  produced  by  calculi. 

Symptomatology. — There  may  be  two  methods  of  invasion — one 
sudden,  with  chills,  fever,  and  pain  in  the  region  of  the  kidney;  the 
other  more  gradual,  with  rigidity  of  the  hip  and  spine  and  flexion  of 
the  femur.  Pain  is  present  and  motion  is  accompanied  by  pain 
which  may  be  referred  to  the  knee,  thigh,  groin,  or  back.  There  is 
usualh^  marked  pain  on  making  extension  of  the  thigh,  which  is 
considered  diagnostic.  There  is  a  constant  temperature  which  is  not 
very  high  at  first.  As  the  disease  progresses,  the  spine  becomes 
curved  with  the  concavity  toward  the  affected  side,  and  the  thigh 
is  constantly  flexed.  Suppuration  may  take  place  and  the  abscess 
may  burrow  between  the  lumbar  muscles  behind  or  the  abdominal 
muscles  in  front  and  be  recognized  as  a  tumor  in  these  locations. 
The  disease  may  last  from  a  few  weeks  to  a  few  months,  and  recovery 
usually  quickly  ensues  after  evacuation  of  the  pus. 

Diagnosis. — The  disease  most  apt  to  cause  confusion  is  hip-joint 
disease.  This  is  slow  in  onset,  with  a  gradual  atrophy  and  limitation 
of  motion  affecting  all  the  movements  of  the  joint  and  not  coming  to 
abscess  much  under  a  year.  In  perinephritis,  the  onset  is  much  more 
sudden  with  deformity  and  abscess  ensuing  within  a  few  weeks  or 
months.  There  is  no  tenderness  in  the  joint  and  flexion  of  the  thigh, 
with  pain  on  extension,  is  the  principal  deformity.  Pott's  disease, 
with  psoas  abscess,  may  be  differentiated  by  an  examination  of  the 
vertebrae  for  caries. 

Prognosis. — Good.  The  cases  will  recover  unless  the  abscess 
ruptures  into  the  peritoneal  cavity. 

Treatment. — The  patient  must  be  kept  quiet  in  the  horizontal 
position.  Sedatives  may  be  given  for  the  pain  and  both  hot  and  cold 
local  applications  tried.  An  early  recognition  and  opening  of  an 
abscess  will  usually  be  followed  by  a  rapid  recovery. 

Tumors  of  the  Kidney. 

Very  rarely  there   may  be  tuberculous  growths  in  the  kidney, 
usually  in  connection  with  a  tuberculous  infiltration  of  other  portions 
of  the  genito-urinary  tract.     The  vast  majority  of  cases  in  which  a 
30 


466  DISEASES  OF  CHILDREN. 

malignant  growth  attacks  the  kidney  in  the  child  are  of  a  sarcoma- 
tous nature.  The  sarcomata  are  primary  growths  in  these  cases  and 
may  be  followed  by  secondary  growths  in  other  organs,  such  as  the 
lungs  or  liver.  The  growth  may  start  in  the  pelvis  of  the  kidney  or 
in  the  adrenals  or  cortex.  The  increase  in  size  is  rapid  and  may 
produce  pressure  effects  on  the  various  abdominal  viscera,  with  ascites 
and  rarely  general  peritonitis.     Generally  only  one  kidney  is  involved. 

Symptomatology. — The  tumor  is  usually  the  first  symptom  to  be 
noted.  It  steadily  grows  until  a  very  great  size  is  reached.  The 
growth  may  usually  be  first  noted  in  the  side  of  the  abdomen,  but  soon 
pushes  forward  to  the  middle,  and  in  a  few  months  may  fill  the  whole 
cavity.  Hematuria  is  sometimes  present,  and  there  is  a  rapid  failure 
of  strength  and  vitality.  There  will  be  pressure  symptoms  according 
to  the  size  and  direction  of  the  growth.  The  patients  rarely  live 
beyond  a  year,  and  frequently  not  so  long  unless  an  operation  is  sue 
cessful. 

Diagnosis. — The  diagnosis  is  made  by  the  rapid  growth  of  a  solid 
abdominal  tumor  in  an  infant  or  a  young  child.  Practically  all 
tumors  of  this  nature  at  this  time  and  in  this  position  are  sarcomata. 

Treatment. — The  tumor  must  be  removed  as  soon  as  recognized. 
While  the  mortality  is  high,  a  certain  number  of  recoveries  have  been 
reported. 

Hydronephrosis. 

Hydronephrosis  is  a  dilatation  of  the  pelvis  and  calices  of  the 
kidney,  often  associated  with  necrosis  of  the  kidney  parenchyma,  due 
to  some  obstruction  to  the  outflow  of  the  urine.  It  is  seen  more 
frequently  in  early  than  late  childhood  and  about  half  the  cases  are 
found  to  be  congenital. 

The  obstruction  may  be  situated  any  where  in  the  genitourinary 
tract  from  the  external  meatus  to  the  calyx  of  the  kidney.  The  fol- 
lowing causes  may  be  noted:  Imperforate  prepuce  or  meatus;  congeni- 
tal stricture  of  the  urethra;  congenital  hypertrophy  of  the  bladder 
wall  inducing  stenosis  of  the  ureters;  misplacement  of  the  ureters; 
valve-like  strictures  in  the  course  of  the  ureter  or  of  the  ostium  pel- 
vicum,  showing  a  reduplication  of  the  mucosa  and  of  the  muscularis 
from  inflammatory  change  or  abnormalities  of  development;  urinary 
calculi  occurring  after  birth  and,  by  their  growth,  occluding  the  uri- 
nary tract;  pressure  by  abnormal  growths  in  neighboring  organs  or 
mechanical  pressure  from  a  floating  kidney;  deformities  of  the  skele- 
ton or  any  foreign  body  in  connection  with  the  genitourinary  tract. 


DISORDERS  OF  THE  URINE  AND  KIDNEYS. 


467 


Hydronephrosis  may  be  unilateral  or  bilateral,  in  the  latter  case 
the  obstruction  usually  exists  in  the  bladder  or  urethra.  The  congen- 
ital form  may  be  either  unilateral  or  bilateral,  but  is  usually  unilateral. 
There  will  be  extensive  dilatation  if  the  obstruction  in  the  urinary 
tract  occurs  before  the  fourth  month  of  intrauterine  life,  as  the  secre- 


FiG.  128. — Bilateral  congenital  hydronephrosis,  caused  by  valve-Hke 
strictures  in  the  ureters.     From  an  infant  26  days  old. 


tion  of  urine  begins  about  this  time.  When  the  hydronephrosis  is 
unilateral,  the  other  kidney  will  functionate  vicariously.  In  some 
cases  the  obstruction  may  be  only  temporary  or  partial,  when  the 
affected  kidney  will  retain  part  of  its  function. 

Cases  of  hydronephrosis  of  both  kidneys  are  fatal  during  infancy, 
and  the  condition  is  usually  overlooked,  the  babies'  dying  of  some 


468 


DISEASES  OF  CHILDREN. 


intercurrent  affection.  In  older  children,  with  the  unilateral  form, 
the  disease  may  be  suspected  or  recognized  when  the  dilatation  is 
sufficient  to  produce  a  tumor  in  the  lumbar  region.  Nephrectomy 
may  then  afford  a  radical  cure  if  the  other  kidney  is  sound.  Where 
hydronephrosis  is  due  to  an  impacted  calculus  in  a  ureter,  the  con- 
dition is  apt  to  eventuate  in  pyelonephritis. 


Enuresis. 

(Incontinence  of  Urine.) 

The  symptom-complex  of  incontinence  of  urine  can  best  be  studied 
by  considering,  first,  the  phenomena  which  accompany  the  voiding  of 
urine  under  the  action  of  the  bladder  reflexes,  and,  second,  the  ana- 
tomical and  physiological  peculiari- 
ties accompanying  this  function  in 
early  life. 

The  bladder,  the  spinal  centers 
innervating  it,  and  the  brain  hold- 
ing an  inhibition  over  the  spinal 
centers,  all  have  a  part  in  this  ac- 
tion. The  following  diagram,  modi- 
fied from  Gowers,  will  give  a  sug- 
gestive idea  of  these  parts : 

In  the  bladder  we  have  the 
sphincter  (S),  guarding  the  outlet 
by  its  tonic  contraction,  and  the 
detrusor  (D),  or  muscle  of  the 
bladder,  usually  distended,  but 
which,  by  its  contraction,  empties 
the  organ.  Both  sphincter  and 
detrusor  are  innervated  by  the 
segments  in  the  spinal  cord  corres- 
ponding to  the  third,  fourth,  and 
fifth  sacral  nerves.  The  motor 
tonic  centers  for  the  sphincter  (MS) 
keep  this  muscle  in  contraction, 
while  the  centers  for  the  detrusor  (MD)  hold  it  in  a  state  of  dilatation 
corresponding  to  a  positive  and  negative,  or  plus  and  minus  action, 
of  the  motor  nerves  MNS  and  MND.  As  the  bladder  becomes 
distended  with  urine,  sensory  impulses  are  transmitted  by  sensory 
nerves  (SN)  to  the  sensory  centers  of  the  cord  (SC)  which  are  con- 
nected with  the  motor  reflex  centers  (MS  and  MD)  by  association  fibers. 


Fig.  129. 


DISORDERS  OF  THE  URINE  AND  KIDNEYS.  469 

When  the  motor  centers  are  sufficiently  irritated  they  reverse  their  ac- 
tion, as  a  negative  impulse  ( — )  is  sent  down  by  the  motor  nerves  MNS 
to  the  sphincter,  which  dilates,  and  a  positive  ( +)  action  is  transmitted 
by  the  motor  nerves  MND  to  the  detrusor  which  promptly  contracts. 

The  action  of  a  physiological,  automatic  reflex  is  thus  shown. 
This  action,  however,  is  held  in  check  by  the  inhibition  of  the  brain 
(B)  that  holds  a  restraining  influence  on  the  spinal  reflexes  by  nerve 
fibers  connecting  with  them  (MT  and  ST).  It  is  usually  necessary 
to  relax  the  inhibition  of  the  brain  before  the  automatic  reflex  can  take 
place.  Urination  is,  therefore,  not  so  much  a  direct  voluntary  action 
as  an  indirect  action  of  the  brain  in  relaxing  its  hold  on  the  spinal 
centers  and  thus  allowing  the  automatic  reflex  full  sway. 

In  early  life  there  are  certain  anatomical  and  physiological  pecu- 
liarities that  render  the  bladder  and  its  reflexes  very  unstable.  While 
the  sphincter  is  weak,  the  detrusor  is  thick  and  powerful.  In  making 
autopsies  on  female  infants  the  bladder,  owing  to  the  thickness  of  its 
wall,  is  sometimes  mistaken  for  the  uterus.  A  powerful  detrusor 
acting  against  a  feeble  sphincter  thus  renders  the  action  of  the  bladder 
in  retaining  the  urine  unstable.  In  early  life  the  spinal  reflexes  are 
also  very  active.  The  motor  areas  of  the  cord  are  relatively  more 
developed  than  the  sensory  part,  and  hence  motor  actions  preponder- 
ate. What  would  cause  a  sensory  disturbance  in  an  adult  is  reflected 
into  a  motor  arc  in  the  child  and  hence  produces  a  motor  disturbance. 
This  is  exemplified  in  the  beginning  of  severe  illness,  especially  in 
acute  infections,  where  the  chill  (sensory  disturbance)  of  the  adult 
is  often  replaced  by  a  convulsion  (motor  disturbance)  in  the  child. 
This  activity  of  the  motor  reflexes  exhibits  many  forms  in  early  life, 
especially  in  infancy,  when  the  action  of  the  spinal  cord  is  most  active, 
and  the  brain  being  as  yet  undeveloped  fails  to  hold  a  proper  inhibition 
on  these  lower  centers.  The  watery  brain  of  the  infant,  with  rela- 
tively little  gray  matter,  cannot  hold  the  active  reflexes  of  the  spinal 
centers  in  proper  equilibrium. 

There  are  two  forms  of  incontinence — active  and  passive:  (a) 
Active  incontinence  is  produced  when  sufficient  urine  is  present  in  the 
bladder  to  cause  enough  irritation  of  the  sensory  nerves  to  induce  a 
contraction  of  the  detrusor  and  dilation  of  the  sphincter  through  the 
spinal  centers.  There  is  no  paralysis,  but  either  a  lack  of  proper  brain 
control  or  overaction  in  the  cord.  In  this  form  the  urine  usually 
■  passes  rapidly  and  in  full  stream,  (b)  Passive  incontinence  is  caused 
by  weakness  or  paralysis  of  the  sphincter,  and  the  urine  usually 
dribbles  away  without  ability  of  control. 

With  the  constant  underlying  predisposition  to  incontinence  in 


470  DISEASES  OF  CHILDREN. 

early  life,  there  are  certain  specific  causes  that  may  be  mentioned  in 
order  to  throw  light  on  treatment:  (1)  Excessive  acidity  of  the 
urine.  Uric  acid  is  readily  formed  in  early  life;  in  new-born  infants 
crystals  are  often  seen  in  the  calices  of  the  Mdney.  The  urine  may 
thus  become  so  irritable  as  to  be  passed  drop  by  drop,  or  with  a 
reddish  tinge  that  simulates  the  appearance  of  blood  on  the  diaper. 
Other  acids,  such  as  the  acid  phosphate  of  sodium  and  lactic  and 
hippuric  acids  may  be  present  in  excess  in  the  urine.  Very  small 
quantities  of  overacid  urine  often  provoke  incontinence  by  irritating 
the  bladder,  and  thus  stimulating  the  nerve  reflexes  to  act.  (2) 
Excessive  irritability  of  the  muscular  coat  of  the  bladder  even  when 
the  urine  is  mildly  acid  or  neutral.  As  the  detrusor  has  an  exaggerated 
contractile  power  in  these  cases,  the  urine  is  passed  in  a  full  and  rapid 
stream.  Even  ordinary  stimulation  often  causes  strong  contrac- 
tion in  the  unstriped  muscular  fibers.  This  explains  why  atropin  or 
belladonna  acts  almost  as  a  specific  when  the  muscle  is  thus  at  fault. 
(3)  Weakness  of  the  sphincter.  This  form  occurs  in  feeble  children 
who  are  in  poor  condition  from  severe  illness  or  underfeeding,  or 
where  the  innervation  of  the  sphincter  has  been  weakened  by  diseases 
of  the  spine  or  spinal  nerves.  The  urine  is  not  passed  rapidly  nor  in 
full  stream,  but  is  more  apt  to  dribble  away.  (4)  Reflex  irritation 
from  disturbances  outside  the  bladder.  The  genitals,  anal  ring  or  rec- 
tum may  present  conditions  producing  sufficient  irritation  to  cause  fre- 
quent contractions  of  the  bladder  under  reflex  action.  Phimosis,  adhe- 
sions of  prepuce  to  glans  with  retained  smegma,  stricture  of  the  urethra, 
balanitis,  vulvitis,  ascarides,  fissure  of  the  anus  and  hard  scybala  in 
the  rectum  may  be  noted  in  this  connection.  (5)  Neurotic  causes. 
Children  with  unstable  nervous  equilibrium  from  chorea,  epilepsy, 
and  similar  conditions  are  prone  to  incontinence  of  urine.  Under 
psychical  influence,  especially  in  dreams,  the  child  imagines  a  con- 
venient place  for  urination  and  the  reflexes  act.  (6)  Vesical  calculus 
may  be  a  rare  cause  of  incontinence,  and,  when  acting,  will  be  both 
diurnal  and  nocturnal,  with  urine  turbid  from  mucopus  and  frequent 
painful  micturition.  (7)  Malformation  of  the  bladder.  Congenital 
deformities,  such  as  extroversion  of  the  bladder,  rectovesical  and 
vesicovaginal  fistulse,  and  a  few  cases  reported  where  ureters  have 
emptied  directly  into  the  urethra,  will  be  accompanied  by  constant 
dribbling  of  the  urine. 

Treatment. — It  is  evident  from  an  enumeration  of  the  different 
causes  that  one  kind  of  treatment  will  not  be  adapted  to  all  cases,  and 
hence  the  physician  must  find,  if  possible,  the  principal  reason  for 
incontinence  by  an  examination  of  the  urine,  together  with  a  general 


DISORDERS  OF  THE  URINE  AND  KIDNEYS.  471 

and  local  physical  examination  of  the  patient.  More  than  one  cause 
will  often  be  found  present.  Highly  acid,  scanty  urine  may  be 
relieved  by  a  free  administration  of  water  together  with  an  alkali, 
such  as  the  acetate  or  bicarbonate  of  potash,  five  grains  of  either 
thrice  daily.  Where  overirritability  of  the  detrusor  is  the  principal 
cause,  belladonna  in  full  physiological  dose,  by  its  action  on  unstriped 
muscular  fiber,  will  usually  diminish  functional  activity  and  thus 
correct  the  condition.  For  a  child  of  five  years,  grain  ^^^  atropin 
sulphate  or  the  tincture  of  belladonna,  n^^.  v,  may  be  given  late  in  the 
day,  and  the  dose  increased  until  there  is  dryness  of  the  throat  and 
flushing  of  the  skin.  If  the  incontinence  is  not  relieved  when  the 
drug  is  pushed  to  its  full  effect,  it  will  not  be  necessary  to  continue  it 
very  long.  Where  there  is  evidence  of  weakness  of  the  sphincter,  nux 
vomica  or  strychnin  and  ergot  Avill  act  in  strengthening  its  tonicity 
and  stimulating  the  nerve  centers.  From  5  to  10  minims  of  fluid 
extract  of  ergot  and  5  minims  of  the  tincture  of  nux  vomica  ma}'  be 
given  thrice  daily,  well  diluted  in  water,  to  a  child  of  five  years. 
Unlike  belladonna,  these  remedies  may  have  to  be  continued  for  sev- 
eral weeks  before  the  full  benefit  is  obtained.  Occasionally  good 
results  will  be  obtained  by  a  few  hypodermatic  injections  of  ten  drops 
of  the  fluid  extract  of  ergot  directly  into  the  ischiorectal  fossa.  Sup- 
positories, containing  half  a  grain  of  ergotin,  may  also  do  good  in  this 
class  of  cases.  Incontinence  of  feces  may  have  the  same  nervous 
causes  and  mechanism  as  incontinence  of  urine  and  may  require  the 
same  treatment. 

The  general  hygienic  treatment  is  always  important.  A  simple, 
unstimulating  diet,  with  a  light  early  supper  is  desirable.  Restriction 
in  the  amount  of  fluids,  especially  late  in  the  day,  may  be  tried. 
Postural  treatment  at  night,  with  the  buttocks  elevated  to  save  the 
neck  of  the  bladder,  has  been  advised,  but  is  impracticable.  General 
tonic  treatment,  such  as  the  use  of  large  doses  of  the  syrup  of  the  iodid 
of  iron  will  relieve  certain  cases.  Cold  bathing,  and  plenty  of  fresh 
air  will  act  as  adjuvants.  Sometimes  a  change  from  one  bed  to  another 
will  bring  at  least  temporary  relief.  The  children  should  be  taken  up 
late  at  night  and  early  in  the  morning,  and  placed  upon  a  commode 
to  prevent  the  bladder  from  getting  too  full.  Punishing  these  children 
is  unavailing  and  usually  makes  the  matter  worse  by  upsetting  the 
nervous  system.  The  trouble  is  apt  to  be  more  frequent  and  intract- 
able in  boys  than  in  girls,  and  in  rare  cases  may  last  for  years.  An 
intelligent  study  of  the  child's  condition  and  a  recognition  of  the 
principal  cause  in  each  case  and  an  adaptation  of  the  treatment  to 
such  specific  cause  will,  however,  usually  bring  relief. 


SECTION  XII. 

DISEASES  OF  THE  GENITAL  ORGANS 
AND  BLADDER. 


CHAPTER   XXXIV. 
DISEASES  OF  THE  GENITAL  ORGANS. 

Phimosis  and  Paraphimosis. 

Phimosis  exists  when  the  prepuce  is  so  narrowed  or  contracted 
that  the  foreskin  cannot  be  freely  drawn  back  over  the  glans. 

Hofmokl  notes  four  causes  of  phimosis: 

(1)  A  prepuce  congenitally  too  long  and  too  narrow  (hypertrophic 
form),  (2)  congenital  narrowness  restricted  to  the  external  opening  of 
the  prepuce,  (3)  long  persistence  of  extensive  epithelial  agglutination 
between  glans  and  prepuce,  (4)  congenital  and  abnormal  shortness 
of  the  frenulum  and  its  location  too  far  toward  the  front. 

Symptomatology. — Urination  is  frequent  and  painful.  When 
about  to  urinate  the  child  is  very  restless,  and  while  voiding  will  often 
cry  out  with  pain.  Older  children  attempt  to  restrain  the  act  as  long 
as  possible.  In  some  cases  the  prepuce  balloons  out  with  urine  as  it 
passes  or  it  may  escape  drop  by  drop.  If  the  foreskin  is  very  tight, 
drops  of  urine  remain  and  decomposition  of  this  retained  urine  often 
produces  an  eczema  at  the  meatus  or  even  on  the  thighs  and  over  the 
entire  genital  region.  Such  inflammatory  processes  may  cause  balan- 
itis. The  habit  of  masturbating  may  be  induced  by  the  irritation. 
Following  such  a  course,  an  infection  may  occur  which  may  ascend 
through  the  urethra,  sometimes,  although  rarely,  causing  urethritis 
and  cystitis.  Dilatation  of  the  bladder  and  hydronephrosis  may  also 
result  in  neglected  cases.  The  increase  of  intraabdominal  pressure 
from  straining  may  produce  a  hydrocele,  a  hernia,  or  prolapse  of  the 
rectum.  Sj^ncope  and  epileptiform  convulsions  were  formerly  erro- 
neously attributed  to  phimosis. 

If  the  foreskin  be  forcibly  retracted  over  the  glans,  the  pres- 
sure of  the  preputial  ring  in  the  coronary  sulcus  may  cause  strangula- 
tion. Such  a  condition  is  known  as  paraphimosis  and  soon  causes 
violent  pain.     If  this   obstruction   to  the  circulation  is  not  relieved 

472 


DISEASES  OF  THE  GENITAL  ORGANS.  473 

edema  and  inflammation  will  occur  which  later  can  produce  ulceration 
and  necrosis  of  the  parts. 

Treatment. — ^The  treatment  of  phimosis  with  adhesions  consists 
in  gently  separating  the  agglutinated  surfaces  with  a  blunt  probe  and 
then  retracting  carefully  the  foreskin  over  the  glans.  If  this  is  not 
easily  accomplished  the  foreskin  may  be  stretched  by  slowly  separating 
the  blades  of  a  forceps  until  it  is  possible.  Any  smegma  which  is 
present  is  wiped  away.  If  urine  is  retained  in  the  foreskin  causing 
decomposition,  circumcision  is  indicated  rather  than  stretching.  To 
relieve  a  paraphimosis,  replace  the  glans  within  the  prepuce  by  using 
the  first  and  second  fingers  of  both  hands  from  below  and  with  the 
thumbs  above,  forcing  the  glans  through  the  constriction.  If  this 
cannot  be  accomplished  by  manipulation,  the  strangulating  ring  must 
be  incised  and  cold  compresses  applied  to  reduce  the  swelling  and  in- 
flammation.    As  a  rule,  circumcision  is  performed  at  a  later  date. 

Balanitis. 

This  condition  is  usually  due  to  an  accumulation  of  smegma  and 
retained  urine,  the  decomposition  of  which  causes  an  inflammation  of 
the  prepuce.  Such  accumulations  occur  most  frequently  where  there 
is  phimosis.  Other  causes  of  balanitis  are  masturbation,  injury,  and 
infection  of  the  mucous  membrane  of  these  parts.  There  is  redness 
and  swelling  of  the  free  margin  of  the  prepuce,  the  opening  of  which  is 
often  covered  by  small  crusts.  Several  drops  of  seropus  may  appear 
if  the  opening  of  the  prepuce  is  separated;  it  is  usually  impossible  to 
retract  the  prepuce  entirely. 

Treatment. — Distend  the  prepuce  by  injecting  an  antiseptic  solu- 
tion, such  as  bichlorid  of  mercury,  1  to  5,000,  or  a  weak  permanganate 
of  potash  solution,  three  or  four  times  a  day.  When  this  cannot  be 
accomplished,  apply  the  antiseptic  dressing  ice-cold.  A  solution  of 
bichlorid  of  mercury  1  to  10,000  or  liquor  Burowi,  one  to  four  parts, 
is  suitable.  The  wet  dressings  are  apphed  until  the  swelling  is  reduced. 
Slitting  up  the  prepuce  to  permit  of  thorough  cleansing  is  sometimes 
necessary  and  then  gives  the  quickest  relief.  All  adhesions  should  be 
removed  when  this  is  done.  Circumcision  at  this  time  should  not  be 
performed. 

Urethritis. 

Urethritis  may  be  simple  or  specific.  In  the  former,  lack  of 
cleanliness,  injury  or  uric  acid  crystals  are  the  usual  causes.  There  is 
pain  on  urination  and  a  slight  discharge  of  pus.     The  inflammation  is 


474  DISEASES  OF  CHILDREN. 

usually  confined  to  the  anterior  portions  of  the  urethra.  There  are  no 
sequela  as  in  the  specific  form.  . 

Infection  causing  specific  urethritis  takes  place  by  direct  con- 
tact and  can  be  diagnosticated  only  by  a  bacteriological  examination. 
Gonococci  are  generally  found  in  great  numbers  in  the  discharge. 
Except  for  the  constitutional  symptoms,  which  are  mild  or  entirely 
absent,  specific  urethritis  gives  the  same  clinical  picture  as  in  adults; 
that  is,  a  thick  purulent  discharge  and  burning  pa.n  on  urination. 
Complications  are  rare;  those  likely  to  arise  are  stricture,  posterior 
urethritis,  epididymitis,  arthritis,  and  gonorrheal  conjunctivitis. 

Treatment. — Urotropin  in  5-grain  doses  three  times  a  day  with 
rest  in  bed  is  usually  sufficient,  but  in  some  obstinate  cases  it  is  neces- 
sary to  irrigate  the  urethra  with  argyrol  in  a  5  per  cent,  solution  or 
potassium  permanganate  in  ^  per  cent,  solution  twice  daily.  The 
pelvis  should  be  covered  to  avoid  carrying  the  infection  to  the  eyes 
and  the  attendants  warned  of  such  danger. 

Vulvovaginitis. 

{Urogenital  Blennorrhea.) 

This  condition  is  a  frequent  cause  of  dysuria  in  girls,  and  may 
occur  under  the  influence  of  general  malnutrition,  as  in  marked 
anemic  conditions,  uncleanliness,  masturbation,  when  parasites  are 
present,  or  following  an  infectious  disease.  The  usual  cause,  however, 
is  an  infection  by  Neisser's  gonococcus. 

In  this  specific  form  infection  takes  place  by  either  direct  sexual 
contact  or  by  handling,  contact  with  the  infected  bed  linen  of  parents, 
and  less  frequently  from  towels  or  discarded  dressings.  Epidemics 
of  vaginitis  frequently  occur  in  hospitals  and  especially  institutions  for 
children. 

Differentiation  of  the  simple  and  gonorrheal  types  is  based  on 
the  bacteriological  examination  of  the  pus. 

Vulvovaginitis  begins  with  redness  and  swelling  of  the  parts  and 
a  discharge  of  pus,  which  is  usually  yellowish  or  white  in  the  simple 
form  and  greenish  in  the  gonorrheal.  The  pus  is  abundant,  and  on 
drying  forms  crusts  causing  the  labia  to  adhere.  Micturition  is 
frequent  and  painful,  due  to  contact  of  the  urine  with  excoriations 
of  the  mucous  membranes  of  the  urethra  and  the  labia.  There  is  also 
pain  on  locomotion,  due  to  the  excoriated  thighs.  In  severe  cases 
pus  may  be  seen  oozing  from  the  cervix.  The  vaginal  mucous  mem- 
brane bleeds  easily,  due  to  the  excoriations  present.  Constitutional 
sj^mptoms  are  infrequent,  but  buboes  occasionally  occur  and  may  even 


DISEASES  OF  THE  GENITAL  ORGANS.  475 

suppurate.  In  the  gonorrheal  form  the  usual  adult  complications 
may  occur,  such  as  arthritis  of  the  large  joints,  conjunctivitis,  and 
cystitis.  Salpingitis  and  general  peritonitis  have  occurred  in  our 
service. 

Treatment. — Treatment  of  all  vaginitis  cases  requires  isolation 
of  the  case  and  scrupulous  cleanliness  as  regards  the  patient,  the  linen, 
and  the  dressings  as  well  as  the  attendant's  hands.  In  severe  cases 
the  patient  should  be  in  bed.  In  the  simple  form,  after  removing  the 
cause,  irrigate  the  parts  two  or  three  times  daily  with  warm  normal 
salt  or  boric  acid  solutions,  bichlorid  of  mercury  1  in  10,000,  silver 
nitrate  solution  1  in  10,000,  or  formalin  solution  1  in  5,000.  Cover  the 
thighs  and  vulva  with  unguentum  zinci  oxidi  or  stearatis.  A  sterile 
pad  is  applied  over  the  parts. 

In  gonorrheal  cases  this  treatment  may  be  supplemented  by  the 
use  of  vaginal  suppositories  of  argyrol  10  per  cent,  in  oleum  theobro- 
matis;  insert  one  after  each  irrigation.  In  all  cases  general  tonics  are 
indicated. 

In  simple  cases  under  treatment  the  course  of  the  disease  is 
about  two  or  three  weeks.  The  gonorrheal  form  lasts  much  longer, 
often  for  months,  and  relapses  are  frequent. 

Vaccine  Treatment. — The  vaccine  treatment  may  be  tried  in 
intractable  cases  or  for  a  series  of  cases  in  an  institution.  A  study 
of  recent  investigations  shows  that  the  injections  of  vaccine  must  be 
controlled  by  determination  of  the  opsonic  indices  of  each  individual 
case,  reinjection  being  made  before  the  index  falls  below  normal. 
A  dose  too  large  or  two  small  gives  little  or  no  response,  five  million 
dead  bacteria  being  the  preferred  initial  dose.  Under  this  treatment 
clinical  evidences  of  gonorrhea  disappear  in  ten  to  twenty-one  days, 
and  no  gonococci  can  be  found  in  the  smears. 

In  some  cases  a  polyvalent  vaccine  seems  more  efficiejnt  than  a 
univalent  one.  The  best  results  are  obtained  when  the  vaccine  used 
is  obtained  from  the  patient's  own  organisms,  except  where  the  case  is 
of  long  duration  or  has  been  treated  by  antiseptics,  as  these  lower  the 
virulency  of  the  organism;  it  is  then  better  to  make  vaccine  from  a 
strain  of  known  high  virulence.  Experiments  have  proved  this 
step  to  be  most  efficient  in  spite  of  Torrey's  conclusion  that  "the 
family  gonococcus  is  heterogeneous." 

If  an  eye  should  become  infected,  the  injections  should  be  made 
at  once  without  determining  the  index  or  waiting  for  the  vaccine  to  be 
made. 

The  frequency  of  injection  depends  on  the  index;  nothing  can  be 
gained  by  more  injections  during  the  negative  phase.     If  the  initial 


476  DISEASES  OF  CHILDREN. 

dose  be  high  the  negative  phase  may  last  two  weeks  or  longer.  It  is 
therefore  better  to  wait  a  longer  rather  than  a  shorter  time  for  the 
second  injection.  As  a  rule,  the  discharge  increases  for  the  first  two 
or  three  days  after  the  injection,  and  then  diminishes  very  rapidly. 
Improvement  is  always  marked  after  the  first  few  days,  and  the  patient 
may  continue  to  gain  during  the  negative  phase;  consequently  clinical 
signs  should  not  be  made  the  guide  for  future  injections.  Index 
determinations  alone  must  be  depended  upon. 

Masturbation. 

In  infants  and  very  young  children,  the  presence  of  some  organic 
source  of  irritation  in  or  about  the  genitalia  is  assumed  as  the  cause  of 
masturbation.  Of  such  irritations  itching,  vulvar  eczemas,  and  pin 
worms  which  have  escaped  from  the  rectum  and  found  their  way  into 
the  vagina  are  the  most  frequent  causes  in  girls.  Attempts  to  relieve 
this  irritation  by  scratching  or  rubbing  the  thighs  together  results  in 
the  persistence  of  the  habit  because  of  the  sensations  it  produces. 
In  boys,  an  elongated  prepuce,  friction  from  a  phimosis,  excoriations 
at  the  meatus  from  a  highly  acid  urine  may  be  the  original  cause. 
In  girls,  adhesions  about  the  clitoris  from  smegma  and  uncleanliness 
are  common  causes. 

In  older  children  the  beginning  of  such  a  habit  is  more  probably 
due  to  acquaintance  with  others  with  whom  the  practice  is  in  vogue; 
in  some  cases,  accidental  discovery  that  genital  irritation  produces 
voluptous  sensations  occurs  in  certain  sports,  such  as  bicycle-riding 
or  tree-climbing. 

It  is  an  error  to  assume  that  this  practice  produces  nervous, 
irritable  children,  with  pallor,  headache,  and  sickly  appearance  and 
dark  rings  under  the  eyes  unless  masturbation  be  indulged  in  to  excess. 
In  children  of  the  neurotic  type  such  symptoms  are,  however,  greatly 
aggravated  by  the  violent  sexual  excitement  so  produced. 

Treatment. — It  is  essential  to  remove  the  cause.  By  the  use  of 
suitable  night  gowns  and  bandages  children  can  be  prevented  from 
masturbation  at  night.  During  the  day  constant  supervision  is 
imperative;  this  is  more  difficult  with  children  of  the  school  age. 
Dietetic  changes  and  psychic  treatment  after  suitable  explanation 
are  potent  factors  in  eradicating  the  habit.  Effort  should  be  made 
to  keep  the  child  occupied  all  the  time  and  frequent  diversion  of  the 
mind  toward  active  and  healthy  normal  channels  will  prove  most 
efficient  measures.  Cold  affusions  to  the  spine  may  be  employed 
in  intractable  cases. 


DISEASES  OF  THE  GENITAL  ORGANS.  477 

Hydrocele. 

When  the  peritoneal  sac  surrounding  the  testicle  and  epididymis 
is-  distended  with  fluid,  the  condition  is  known  as  hydrocele.  It  is 
not  uncommon,  and  is  usually  congenital  in  origin. 

The  following  varieties  may  be  differentiated: 

Hydrocele  of  the  Tunica  Vaginalis  (with  the  funicular  process 
obliterated). — This  is  one  of  the  most  common  forms  found  in  children. 
The  tumor  formed  is  oval  and  is  firm  and  tense.  It  may  occur  on 
one  or  both  sides.  The  tumor  cannot  be  reduced.  Fluctuation  can 
usually  be  obtained,  and  the  site  of  the  testicle  can  be  seen  by  illumina- 
tion of  the  scrotum.  The  cord  is  felt  above  the  rounded  upper  portion  of 
the  swelling,  and  the  testis  is  generally  situated  posteriorly,  projecting 
into  the  cavity,  and  is  therefore  not  readily  detected  by  manipulation. 

Congenital  hydrocele  exists  when  the  funicular  process  is 
patent.  The  signs  above  stated  exist  except  that  upon  manipulation 
the  fluid  can  be  returned  to  the  abdominal  cavity. 

Infantile  hydrocele  occurs  when  the  funicular  process  is 
closed  at  its  upper  extremity  only.  The  fluid  extends  along  the  cord, 
and  the  tumor  is  therefore  elongated;  the  other  signs  are  the  same 
as  given  above. 

Encysted  hydrocele  of  the  cord  is  one  in  which  there  is  an 
additional  point  of  obliteration  of  the  intraabdominal  portions  of 
the  funicular  process  above  the  internal  abdominal  ring;  fluid  distend- 
ing this  portion  of  the  canal  forms  a  tumor  resembling  a  cyst  iit. addi- 
tion to  the  tumors  in  the  scrotum. 

Treatment. — As  a  rule,  no  treatment  is  required.  After  several 
weeks  the  condition  spontaneously  disappears.  If  phimosis  is  present 
this  should  be  corrected  at  once.  In  more  resistant  cases  puncturing 
the  sac  and  allowing  the  fluid  to  thoroughly  drain  off  usually  produces 
a  cure.  If  relapses  occur,  instillating  one  or  two  drops  of  the  tincture 
of  iodin  in  ten  drops  of  water  will  set  up  adhesions  sufficient  to  ob- 
literate the  sac.  In  some  of  the  congenital  forms,  a  truss  may  be  applied 
in  order  to  obliterate  the  funicular  process,  and  then  if  a  cure  is  not  af- 
fected aspiration  is  performed.  If  the  hydrocele  is  associated  with  a  her- 
nia a  suitable  truss  must  be  worn  after  the  evacuation  of  the  fluid. 

Undescended  Testicle. 

(Cryptorchidism.) 

When  not  in  the  scrotum,  the  testis  may  be  found  (1)  in  the  ab- 
dominal cavity  attached  to  the  abdominal  wall  or  (2)  just  inside  the 


478  DISEASES  OF  CHILDREN. 

internal  abdominal  ring  or  (3)  as  is  most  common,  in  the  inguinal  canal 
or  (4)  just  beyond  it. 

The  causes  of  such  a  malformation  may  be  a  short  or  abnormally 
attached  gubernaculum,  a  contracted  external  ring,  or  an  abnormally 
large  epididymis. 

The  diagnosis  is  made  when  the  scrotum  is  found  empty  on  the 
affected  side,  and  a  small  movable  tumor  the  size  of  a  hazelnut  is  found 
in  the  inguinal  region  which  gives  the  unpleasant  testicular  sensation 
on  pressure. 

If  no  symptoms  arise  the  best  treatment  is  neglect;  if,  however, 
there  is  much  pain  or  tenderness  which  sometimes  occurs  when  the 
testicle  is  in  the  canal,  surgical  intervention  is  required.  The  surgeon 
may  succeed  in  drawing  the  testicle  down  into  the  scrotum  or  he  may 
be  obliged  to  replace  it  in  the  abdomen. 

If  the  testicle  lies  within  the  abdomen  and  develops  there,  its' 
function  is  not  interfered  with.  When  it  is  subjected  to  constant  pres- 
sure within  the  inguinal  canal,  such  compression  may  hinder  develop- 
m3nt  or  lead  to  atrophy. 

Differential  Diagnosis  of  Swellings  in  the  Inguinal  Region. 

Swellings  in  the  inguinal  region  are  either  fluctuant  or  non-fluc- 
tuant. If  fluctuation  be  present  the  tumor  may  be  an  abscess  or  a 
hydrocele.  If  an  abscess  be  probable,  there  may  be  a  history  of  vulvo- 
vaginitis, urethritis,  scabies,  or  other  irritant  lesions  about  the  genitals, 
and  the  patient  will  have  some  degree  of  increased  temperature  and 
a  leukocytosis.  Caries  of  the  vertebra  may  produce  a  psoas  abscess. 
If  hydrocele  be  suspected,  the  history  may  show  that  the  tumor  has 
persisted  since  birth  or  that  there  has  been  an  injury.  The  tempera- 
ture and  the  blood  count  will  be  normal,  and  the  light  test  will  be 
positive.  On  percussion  of  a  hydrocele  or  an  abscess  the  note  is  dull  ' 
and  not  tympanitic  as  it  may  be  in  hernia.  A  hydrocele  with  patent 
funicular  process  may  recede  under  moderate  pressure,  but  no  gurgling 
is  felt  as  in  the  reduction  of  hernial  contents. 

In  tumors  without  fluctuation,  hernia,  undescended  testicle,  or 
enlarged  inguinal  glands  may  be  suspected. 

If  the  condition  be  hernia,  the  percussion  note  is  resonant;  if 
reducible,  the  tumor  disappears  quickly  and  is  accompanied  by  a    ' 
gurgling  sound;  the  external  abdominal  ring  is  patent  and  there  is  an 
impulse  on  crying  or  coughing;  there  is  opacity  when  tested  by  trans- 
mitted light. 

If  the  tumor  is  an  undescended  testicle,  the  corresponding  side 


DISEASES  OF  THE  GENITAL  ORGANS.  479 

of  the  scrotum  will  be  found  empty;  the  tumor  is  dull  on  percussion, 
freely  movable,  and  hard.  On  pressure,  the  characteristic  testicular 
sensations  can  be  elicited  in  older  boys. 

If  the  swelling  is  due  to  the  presence  of  enlarged  inguinal  glands 
there  will  probably  be  an  existing  cause  found  in  the  genital  region,  such 
as  eczema,  vulvovaginitis,  scabies,  etc.  Such  tumors  are  dull  on 
percussion,  and  hard  and  freely  movable  unless  suppurating.  In  these 
cases  the  testicle  will  be  found  in  its  normal  place.  Enlarged  glands 
are  usually  multiple. 

Frequently  hernia  and  hydrocele  occur  simultaneously,  and  in 
such  cases  the  diagnosis  is  more  difficult. 


CHAPTER  XXXV. 
DISEASES  OF  THE  BLADDER. 

Cystitis. 

In  infants,  two  forms  are  distinguishable,  one  presenting  general 
symptoms,  including  restlessness,  anorexia,  fever,  pallor,  and  debility, 
but  without  urinary  symptoms;  the  other  with  the  above  general  pic- 
ture, but  with  symptoms  showing  urinary  involvement,  such  as  in- 
creased frequency  of  urination,  pain  or  difficulty  in  voiding,  abdominal 
colic,  tenderness  over  the  bladder,  and  redness  about  the  meatus. 

A  frequent  cause  of  cystitis  is  infection  by  the  bacillus  coli, 
either  alone  or  in  mixed  infection,  and  such  infections  are  termed  coli- 
cystitis.  Many  other  organisms  are  also  found  as  the  causative  factor 
but  are  of  far  less  frequent  occurrence. 

In  colicystitis,  the  urine  shows  the  following  characters;  it  is 
turbid,  acid  in  reaction,  and  contains  albumin  (usually  less  than  y^% 
per  cent.)  pus-cells  and  bacteria,  a  pure  culture  of  bacillus  coli  being 
frequently  obtainable.  The  acid  reaction  of  the  urine  in  cases  of  cysti- 
tis signifies  infection  by  the  bacillus  coli  or  the  bacillus  tuberculosis; 
the  latter  is  very  rare  as  a  primary  infection,  but  does  occur  with  general 
tuberculosis  or  when  the  kidneys  or  genitals  are  involved  in  tubercu- 
lous lesions. 

When  due  to  infection  by  the  pyogenes,  the  reaction  is  alkaline. 
In  cases  of  such  origin,  the  symptomatology  is  much  the  same  as  in 
colicystitis,  but  the  disease  is  more  severe.  In  pyogenic  infections, 
blood  is  often  found  in  the  urine.  Pfaundler's  thread  reaction  may 
be  of  service  in  doubtful  cases  (see  p.  55). 

Treatment. — The  remedy  par  excellence  for  cystitis  is  hexamethy- 
lenetetramin  (urotropin) ;  infants  may  be  given  two  grains  every  four 
hours;  older  children  5  to  7^  grains  every  four  hours.  Salol  in  the 
same  doses  is  also  useful,  but  not  quite  as  effective.  Chronic  cases  may 
require  irrigation  of  the  bladder;  in  such  cases  boric  acid  solution  1 
per  cent,  or  silver  nitrate  solution  1  in  5.000  are  the  best  solutions  to 
use. 

In  all  cases  give  plenty  of  alkaline  waters  to  drink,  avoid  salty 
foods  and  spices,  and  keep  the  patient  in  bed  while  the  acute  symptoms 
persist. 

480 


DISEASES  OF  THE  BLADDER.  481 

Vesical  Spasm. 

Spasm  of  the  sphincter  muscle  of  the  bladder  often  occurs  in 
3'oung  children  due  to  a  variety  of  causes;  for  example,  dysentery, 
anal  fissure,  parasites,  inflammations  in  the  neighboring  parts,  as  Pott's 
disease,  and  lesions  in  the  rectum,  pelvis,  or  perineum.  Occasionally  in 
older  children  a  brief  spasm  occurs  due  to  certain  drugs,  such  as  tur- 
pentine, or  to  sudden  exposure  or  local  chilling,  as  a  cold  closet.  The 
usual  cause  of  spasm  of  the  sphincter  is  the  irritant  effect  of  a  highly 
acid  or  concentrated  urine  on  the  bladder  walls.  The  most  prominent 
symptom  is  frequent  micturition,  each  act  often  yielding  but  a  few 
drops  of  urine.  Pain  is  severe  and  is  accompanied  by  marked  vesical 
and  rectal  tenesmus,  but  no  blood  is  present  in  the  urine. 

Treatment. — Treatment  consists  in  the  removal  of  the  cause  in 
conditions  other  than  that  due  to  the  urine  itself.  When  the  spasm 
is  due  to  the  urine,  the  treatment  consists  in  copious  draughts  of 
alkaline  water  and  the  administration  of  potassium  acetate  or  citrate 
in  doses  of  two  to  five  grains  with  the  tincture  of  belladonna  or  the 
tincture  of  hyoscyamus  one  to  four  drops  every  two  or  three  hours. 

Vesical  Calculus. 

The  severest  dysuria  of  the  chronic  type  may  be  produced  by  a 
vesical  calculus.  This  condition  rarely  occurs  in  children,  while  in 
infants  it  is  still  less  frequent.  A  sudden  stopping  of  the  stream  of 
urine  is  the  most  characteristic  symptom,  although  diurnal  inconti- 
nence is  occasionally  the  evidence  which  may  call  to  mind  the  possi- 
bility of  the  presence  of  a  calculus.  Pain  on  urination  often  occurs 
and  is  usually  felt  in  the  end  of  the  penis  or  in  the  perineum.  Rectal 
tenesmus  with  prolapse  is  frequently  present,  due  to  straining  when  cal- 
culi exist.  On  account  of  the  genital  irritation  in  this  condition  mas- 
turbation is  often  practised.  Urinary  changes  differ  from  those  in 
adults  in  that  hematuria  is  rare,  and  pus  and  mucus  are  infrequent  or 
occur  in  small  quantities.  A  positive  diagnosis  is  made  when  the 
stone  is  felt  by  bimanual  rectal  examination  or  by  searching  the 
bladder  with  a  sound  or  wax-tipped  catheter. 

The  treatment  is  surgical.  Removal  through  suprapubic  incision 
is  usually  necessary. 


31 


SECTION  XIII. 
DISEASES  OF  THE  NERVOUS  SYSTEM. 


CHAPTER  XXXVI. 

GENERAL  NERVOUS  DISEASES. 

General  Consideration. 

To  the  unstable  equilibrium  of  the  rapidly  developing  brain, 
to  its  peculiar  sensitiveness  to  peripheral  irritation,  to  the  important 
role  played  by  the  infectious  diseases,  the  liability  of  the  child  to  trau- 
matism, and  finally  to  hereditary  influences,  singly  or  combined  with 
any  of  the  above,  must  be  attributed  the  many  neurotic  disorders 
which  are  peculiar  to  early  life. 

A  full  and  detailed  history  will  be  of  great  assistance  in  arriving 
at  a  diagnosis  in  this  class  of  cases.  A  careful  and  complete  physical  ex- 
amination should  be  made  with  the  child  entirely  naked.  Trained  ob- 
servation for  details  coupled  with  logical  reasoning  will  be  required  for 
success  in  many  instances.  Certain  cases  if  once  seen  in  life  are  rarely 
mistaken,  as,  for  example,  cretinism;  on  the  other  hand,  an  unusual  case 
of  multiple  neuritis  may  require  a  complete  knowledge  of  the  methods 
of  examination,  and  the  diagnosis  will  have  to  be  supported  by  a 
differential  diagnosis,  consciously  or  unconsciously  made  by  the 
physician.  The  sensory  disturbances  are  elicited  with  difficulty  in 
early  life,  and  the  muscle  tone  must  be  interpreted  also  from  the 
view-point  of  the  history  of  previous  feeding. 

The  gait  should  be  carefully  observed,  as  some  are  quite  charac- 
teristic of  certain  groups  of  cases,  for  example,  the  cross-legged  pro- 
gression, or  scissors  position,  indicates  a  spastic  paraplegia.  The 
spastic  gait  is  seen  in  cerebral  palsies,  while  the  ataxic  gait  is  assumed 
by  children  suffering  with  cerebellar  disease,  neuritis,  or  the  more  rare 
disease,  hereditary  ataxia.  The  swinging  gait  of  poliomyelitis  is 
distinguishable  from  the  waddling,  swaying  gait  seen  in  those  with 
the  various  dystrophies.  As' the  cooperation  of  the  patient  is  not 
always  obtainable  and  the  mother's  statements  may  be  innocently 
misleading,  tests  should  be  made  for  blindness  and  hearing.  A  candle 
or  bright-colored  objects  may  be  presented  to  the  eyes  as  a  test. 

482 


GENERAL  NERVOUS  DISEASES.  483 

Vision  may  be  tested  with  the  cards  described  on  page  573.  The 
finger  will  be  allowed  to  touch  the  eyeball  in  absolute  blindness, 
but  if  the  corneal  reflex  is  present  there  will  be  prompt  closure.  An 
ophthalmoscopic  examination  is  feasible  after  proper  preparation  with 
atropin.  Mummying  the  child  as  for  intubation  may  be  necessary 
with  intractable  children.  It  should  be  recollected  that  inequality 
of  the  pupils  and  even  nystagmus  may  be  congenital. 

The  hearing  may  be  estimated  by  clapping  the  hands  suddenly 
behind  the  child,  by  the  use  of  a  whistle,  or  the  whispered  voice. 
Where  an  intelligent  response  may  be  expected  the  tuning-fork  can 
be  used.  Tickling  or  pinching  the  toes  or  fingers  may  be  used  as 
a  test  for  actual  paralysis.  It  should  be  remembered  that  both  upper 
extremities  are  rarely  paralyzed  in  children.  That  the  patellar  reflex 
may  be  obscured  by  fatty  deposits,  and  that  it  should  be  relied  upon 
only  after  obtaining  the  same  result  after  repeated  tests.  Ankle 
clonus,  however,  is  always  indicative  of  an  abnormal  condition.  The 
superficial  reflexes  are  of  little  or  no  value  in  the  early  years.  The 
Babinski  reflex,  extension  of  the  big  toe,  is  of  no  significance  in  the 
first  year  of  life,  being  normal  during  this  period. 

When  the  electrical  examination  is  made  in  children,  great  care 
should  be  employed  not  to  frighten  the  patient;  allowing  them  to 
play  with  the  electrodes  at  first  is  a  good  plan.  Use  the  mildest  cur- 
rents that  will  produce  results,  and  compare  the  reaction  to  the  oppo- 
site extremity.  The  behavior  of  the  muscle  in  reacting  is  often  suffi- 
cient to  appreciate  degenerative  changes. 

Paralysis   in   General. 

Paralysis  or  the  loss  of  motor  power  may  be  associated  with 
sensory  and  reflex  disturbances  and  with  atrophy  of  muscle.  The 
motor  inability  may  be  locaHzed  and  result  in  a  monoplegia,  that  is, 
a  paralysis  of  one  extremity,  diplegia  in  which  both  sides  are  in- 
volved, paraplegia  in  which  the  two  lower  limbs  are  paralyzed,  and 
hemiplegia  or  a  paralysis  of  one  half  of  the  body. 

Again  paralyses  are  spoken  of  as  central  when  they  are  due  to 
lesions  of  the  brain.  Spinal,  when  they  originate  in  the  cord;  periph- 
eral, when  the  result  of  nerve  or  muscle  disease. 

General  Characteristics  of  the  Various  Types — Cerebral  Paralysis 
(Spastic  Paraplegia). — This  is  commonly  unilateral,  the  lesion  being 
on  the  opposite  side  of  the  cortex;  the  face  is  partially  involved. 
Spasticity,  increased  reflexes,  slight  electrical  changes  and  no  atrophy 
of  muscle  distinguish  this  type. 


484  DISEASES  OF  CHILDREN. 

Spinal  Paralysis. — Flaccidity  with  wasting  of  muscle  indicates 
involvement  of  the  peripheral  motor  neuron.  There  is  no  disturbance 
of  sensation  (except  in  myeHtis).  The  reflexes  are  absent  or  dimin- 
ished, and  the  reaction  of  degeneration  is  present. 

Nerve  Paralysis. — The  toxic  forms  are  apt  to  be  bilateral  in  distri- 
bution, the  reflexes  are  lost  and  so  also  is  muscle  excitability.  The 
traumatic  paralyses  are  due  to  pressure  on  the  nerves,  as  a  result  of 


Fig.  130  — Volkman's  ischemic  paralysis,  following  fracture  of  the  radius. 

fracture,  dislocation,  and  pressure  from  without.  They  are  local  in 
distribution  and  if  there  is  response  to  electrical  stimuli,  the  nerve  re- 
covers its  function. 

Muscle  Paralysis. — The  motor  inability  is  here  due  to  the  changes 
in  the  muscle  fibers  themselves.  There  is  diminished  electrical  reac- 
tion and  atrophy  or  pseudohypertrophy  of  muscle.  Diseases  of  the 
joints,  bones,  and  tendons  may  by  atrophy  and  disease  produce  a 
paralytic  condition,  as  in  rheumatoid  arthritis. 

Pseudoparalysis. — True  paralysis  may  be  simulated  by  muscle 
weakness,  as  in  rachitis  or  chorea.  Close  observation  and  the  electri- 
cal reaction  easily  distinguish  the  condition. 

Convulsions. 
(Eclampsia  Infantum.)  ' 

This  symptom  or  symptom-complex  results  from  a  cerebral  irrita- 
tion producing  a  temporary  unconsciousness,  attended  by  irregular 
muscular  contractions. 


GENERAL  NERVOUS  DISEASES.  485 

The  symptom  in  the  infant  and  young  child  often  corresponds  to 
the  chill  of  the  adult.  It  is  quite  commonly  observed  because  of  the 
relatively  greater  excitability  of  the  brain  and  the  undeveloped 
power  of  inhibitory  control.  We  may  divide  the  causative  factors 
into  two  groups — the  reflex  or  functional  and  the  organic. 

Etiology. — The  peripheral  disturbances  which  may  cause  a  con- 
vulsive seizure  are  many  and  various.  The  susceptible  age  is  in  the 
first  two  years  of  life.  An  apparently  trivial  cause,  such  as  psychic  or 
sensor)^  impressions  resulting  from  unusual  excitement  in  a  child  with 
an  inherited  unstable  equilibrium,  may  produce  a  typical  seizure. 
Foreign  bodies  in  the  nose  or  ears,  traumatism,  intestinal  parasites, 
preputial  abnormalities,  improper  or  indigestible  articles  of  food, 
poisons,  and  the  toxemias  resulting  from  or  preceding  certain  diseases, 
as  rachitis,  malaria,  or  tetany,  are  among  the  causes  producing  con- 
vulsions. Rachitis  deserves  special  mention  as  an  underlying  predis- 
posing cause  because  of  the  nervous  instability  it  produces. 

The  organic  causes  are  meningeal  hemorrhages  at  the  time  of 
birth,  tumors  of  the  brain,  cerebral  abscess,  hydrocephalus,  and  the 
various  forms  of  inflammation  of  the  brain  or  its  coverings.  It 
should  be  recollected  that  regional  as  distinguished  from  general 
convulsions  are  indicative  of  organic  lesions,  and  also  that  re- 
peated seizures  over  prolonged  periods  are  characteristic  of  cortical 
disease.  ' 

Description  of  the  Symptom-complex. — The  attack  begins  without 
warning.  It  may  be  preceded  by  slight  twitching  of  the  face  and 
rolling  of  the  eyes.  There  is  then  unconsciousness,  the  eyes  are 
fixed  and  staring,  tonic  rigidity  of  the  head,  back,  and  extremities  is 
shortly  followed  by  clonic  contractions  of  the  facial  muscles.  These 
usually  begin  at  the  mouth,  causing  grimaces  and  distortions  of  ex- 
pression and  some  frothing.  The  teeth  are  firmly  set.  The  color  is 
dusky.  In  a  general  convulsion  all  the  extremities  show  clonic  con- 
tractions and  purposeless  activity.  The  pupils  are  usually  dilated 
and  do  not  react  to  stimuli.  The  respirations  are  labored,  affecting 
the  pulse  and  causing  irregularity  of  the  heart  action  and  increasing 
the  cyanosis.  There  may  be  involuntary  passage  of  urine  and  feces. 
After  a  variable  time  the  muscular  twitchings  cease  and  the  child 
passes  from  a  coma  into  a  deep  sleep.  The  attacks  may  be  and 
usually  are  shortly  repeated  unless  influenced  by  treatment.  After 
a  period  of  sleep  the  child  arouses  and  takes  a  normal  interest  in  its 
surroundings;  it  may  then  be  considered  free  from  the  danger  of 
another  immediate  attack. 

Prognosis. — This  is  usually  good,  but  should  be  guarded  until 


486  DISEASES  OF  CHILDREN. 

a  definite  cause  is  established.  It  is  always  serious  if  the  attacks 
occur  in  the  new-born  in  advanced  childhood,  or  if  they  are  unduly 
prolonged  and  recur  often.  If  convulsions  usher  in  a  disease  they  are 
not  of  as  great  prognostic  importance  as  when  they  occur  in  the 
course  of  the  disease.  An  exception  to  this  statement  must  be  made 
in  cerebrospinal  meningitis  in  which  initial  convulsions  are  of  bad 
omen. 

Differential  Diagnosis. — The  essential  characteristics  are  tempo- 
rary unconsciousness  and  irregular  muscular  contractions. 

In  convulsions  from  organic  causes,  the  regional  involvement, 
often  neuritis,  and  the  resulting  paralysis  may  be  distinguishing 
features.  Epileptic  seizures  occur  usually  after  the  second  year 
of  life,  they  are  apt  to  recur  after  longer  periods  and  without  an 
immediate  causative  factor.  The  history  of  predisposition  may  be 
obtained. 

Treatment. — ^First  overcome  the  attack  or  symptom.  Some  one 
in  the  family  will  in  all  probability  have  given  a  mustard  bath  before 
the  arrival  of  the  doctor.  If  the  attack  persists  inhalations  of  a  few 
drops  of  chloroform  may  be  given  and  if  there  is  any  fever  an  ice-bag 
is  placed  to  the  head.  Meanwhile  a  soap-suds  enema  is  prepared  and 
given  on  general  principles.  If  there  is  an  elevation  of  temperature, 
the  enema  may  be  given  cool  at  70°  F.  Examine  the  fecal  discharge 
for  a  possible  etiological  factor  as  some  foreign  substance  ingested  or 
for  intestinal  parasites.  Keep  the  room  noiseless.  Follow  the  enema 
by  a  rectal  injection  of  the  bromid  of  soda  grains  ten,  and  chloral 
hydrate  grains  three,  for  a  five-year-old  child,  if  the  twitching  still 
persists.  When  the  child  can  swallow,  calomel  or  castor  oil  is  given 
to  rid  the  intestinal  canal  of  possible  toxins. 

In  the  period  of  quiescence  obtain  a  careful  history,  make  a 
detailed  examination  and  arriving  at  a  diagnosis  order  such  treatment 
as  is  suited  to  the  underlying  cause  as,  for  example,  a  properly 
balanced  diet  with  sufficient  proteins  and  fats  for  rachitis. 

Chorea. 

(St.  Vitus'  Dance;  Sydenham' s  Chorea;  Chorea  Minor.) 

Chorea  is  a  neurotic  affection,  characterized  by  purposeless  move- 
ments of  various  parts  of  the  body. 

Etiology. — Girls  are  more  often  affected  than  boys.  It  appears 
most  frequently  from  the  fifth  to  the  twelfth  years  of  life.  Rheu- 
matism and  tonsillitis  are  antecedent  causes.  It  may  develop  as  a 
result  of  fright,  excessive  school  duties,  intestinal  autointoxications, 


GENERAL  NERVOUS  DISEASES.  487 

or  imitation  of  other  choreic  children.  The  offspring  of  neurotic 
parents  are  esiDecially  predisposed. 

Pathology. — The  theory  that  rheumatism,  chorea,  and  endocardi- 
tis are  related  in. many  instances  is  gaining  ground,  and  is  certainly  clini- 
cally of  value.  The  toxin  of  rheumatism  may  affect  the  heart  or  the 
cortex  of  the  brain  in  the  Rolandic  area,  and  causing  irritation  produce 
the  characteristic  movements  seen  in  chorea. 

Hypertrophied  tonsils  and  valvular  disease  are  not  infrequently 
associated  with  chorea.  The  infectious  theory  is  held  by  the  majority 
of  pathologists  to-day  and  these  same  observers  believe  in  the  infec- 
tious character  of  rheumatism  and  endocarditis. 

Symptomatology. — The  symptoms  usually  come  on  insidiously,  and 
may  not  be  noticed  until  quite  marked.  The  child  is  chided  for  care- 
lessness or  awkwardness  in  dropping  articles  or  for  unnecessarily  fid- 
getting.  Nervousness  and  irritability  of  temper  are  noticeable.  Upon 
little  or  no  provocation  the  child  begins  to  cry.  The  muscles  in 
various  parts  of  the  body  later  begin  to  twitch  and  contract,  the  face 
making  ludicrous  grimaces.  These  movements  are  entirely  involun- 
tary, and  if  the  examiner  fixfes  the  child's  attention,  these  irregular 
movements  are  exaggerated.  In  the  early  stages  the  body  move- 
ments may  be  slight  and  are  best  felt  when  the  child's  hands  are  placed 
within  those  of  the  examiner  and  the  arms  put  on  a  slight  tension. 
The  tongue  also  when  closely  observed  shows  the  twitching  movements 
quite  early  in  the  disease.  During  sleep  the  movements  cease.  Fol- 
lowing a  severe  fright  or  chastisement  chorea  may  suddenly  develop 
with  well-marked  symptoms.  Aggravated  cases  or  those  under  no 
control  are  often  pitiably  affected;  the  child  cannot  dress  or  feed  itself; 
sleep  is  disturbed;  speech  is  altered  and  may  be  so  changed  as  to  be 
unintelligible.  Pseudoparalysis  due  to  muscular  weakness  may 
occur  but  the  extremity  is  never  completely  at  rest  for  any  length  of 
time.  On  the  other  hand,  a  case  recently  under  our  observation  in 
the  Post-graduate  Hospital  had  such  marked  jactations,  that  she 
had  to  be  fastened  in  bed  and  fed  by  gavage  until  relief  of  symptoms 
was  obtained  by  medication. 

Hemichorea,  in  which  the  movements  are  confined  to  one  side,  is 
sometimes  seen,  and  in  these  cases  sensation  is  somewhat  impaired  on 
the  same  side. 

There  is  no  elevation  of  temperature,  unless  the  case  is  compli- 
cated with  rheumatism  or  endocarditis.  It  is  not  uncommon  to  find 
a  mitral  regurgitant  murmur  develop  during  the  attack.  Sometimes, 
in  fact,  it  may  precede  it.  Functional  or  anemic  murmurs  are  heard 
in  prolonged  cases. 


488  DISEASES  OF  CHILDREN. 

Course  and  Prognosis. — Chorea  is  in  itself  almost  never  fatal. 
Uncomplicated  cases  tend  to  recover  in  from  one  to  several  months. 
Ten  weeks  is  the  duration  in  the  average  case.     Relapses  are  frequent. 

Diagnosis. — This  is,  as  a  rule,  quite  simple,  resting  upon  the 
characteristic  muscular  movements  and  especially  the  abnormal 
movements  of  the  tongue.  Imitative  choreic  movements  are  dis- 
tinguished by  their  short  duration,  while  in  hysterical  chorea  the 
harmonious  character  of  the  movements  and  other  hysterical  phe- 
nomena serve  to  distinguish  the  neurosis.  Sachs  calls  attention  to  the 
fact  that  choreic  movements  may  be  associated  with  infantile  cerebral 
palsies  and  must  be  distinguished  from  true  chorea.  Spasticity  and 
the  increased  reflexes  should  here  put  the  examiner  on  the  right  track. 

Complications. — Acute  or  subacute  rheumatism,  and  heart  disease 
are  the  most  frequent  complications. 

Treatment. — The  treatment  differs  for  the  mild  and  severe  cases. 

Mild  Cases. — Rest  is  the  first  and  most  important  measure.  With- 
out it  all  treatment  is  unsatisfactory.  The  child  should  be  immedi- 
ately removed  from  school.  By  rest  is  here  meant  avoidance  of  all 
mental  excitement  or  effort;  physical  rest  is  obtained  by  putting  the 
child  to  bed  in  a  well-ventilated  room,  and  keeping  it  there  until  the 
coarser  movements  cease,  then  the  child  may  be  allowed  up  for  a  half- 
hour  in  the  same  room,  and  this  allowance  increased  from  time  to 
time  if  good  progress  is  made.  Toys  which  require  no  effort  on  the 
part  of  the  child  are  allowed,  while  reading  and  singing  to  the  patient 
by  the  attendant  serves  to  shorten  the  enforced  rest.  Visitors  and 
the  other  members  of  the  family  are  to  be  excluded.  The  diet  is  to 
be  carefully  supervised.  Milk  alone  for  a  few  days  and  later  cereals 
and  vegetables,  eggs  and  butter  are  allowed.  Alcohol  sponge  baths 
or  brine  baths  for  their  tonic  effect  may  be  given  daily.  Arsenic  in  the 
form  of  Fowler's  solution  is  given  as  an  adjuvant,  but  should  not  be 
depended  upon  to  cure  the  patient  without  the  rest  treatment,  as  it  is 
far  from  being  a  specific.  Begin  with  three  drops  three  times  a  day 
for  a  five-year-old  child  and  increase  gradually  by  one  drop  up  to 
thirty  drops  daily.  The  arsenic  should  be  administered  after  meals, 
well  diluted  in  some  alkaline  water.  It  must  be  stopped  if  there  is 
any  nausea  or  puffiness  of  the  eye-lids.  In  rheumatic  cases  novaspirin 
or  the  salicylate  of  soda  may  be  given  in  conjunction  with  the  above 
treatment. 

Severe  Cases. — The  rest  cure  is  imperative.  A  padded  bed  is 
sometimes  necessary.  The  movements  should  be  quickly  controlled 
by  doses  of  the  bromids  with  chloral  per  os  or  per  rectum,  and  then 
the  arsenic  treatment  may  be  begun.     If  the  chloral  and  bromids  are 


GENERAL  NERVOUS  DISEASES.  489 

not  sufficient  to  control  the  jactations,  a  hypodermatic  dose  of-hyos- 
cin  hydrobromate  grains  2^^^  for  a  five-year-old  child  will  do  so.  This 
should  not  be  used  if  there  is  any  heart  involvement.  Veronal,  grains 
3,  at  night  will  promote  sleep  if  there  is  insomnia.  Feeding  through 
a  tube  must  occasionally  be  practised.  It  is  best  to  order  a  certain 
fixed  amount  of  nourishment  to  be  taken  or  fed  during  the  day. 

Convalescence. — School  duties  should  be  abandoned  for  some 
months.  Life  in  the  country,  at  the  seaside,  or  in  a  suburban  town 
is  advisable.  Baths,  iron  tonics,  and  nutritious  diet,  including  the 
fats  and  meats,  are  now  indicated,  for  profound  anemias  are  often  con- 
current with  chorea  and  lead  to  relapses  unless  corrected.  School 
life  must  not  be  resumed  until  such  time  as  the  possibility  of  a  recur- 
rence is  well  past. 

Forms  of  Chorea, — Choreiform  affections  or  movements  are  prac- 
tically synonymous  with  habit-spasms  and  tics.  (See  page  500.) 
Huntington's  chorea  or  hereditary  chorea  is  a  rare  disease  of  a  chronic 
nature  and  occurs  in  later  life. 

Chorea  insaniens  is  a  fatal  form,  which  may  be  due  to  a  bacter- 
emia. Chorea  major  is  a  hysterical  chorea  under  which  are  included 
several  groups  described  mainly  by  German  writers,  for  example 
chorea  electrica. 

Hysteria. 

True  hysteria  is  a  rare  disease  of  early  life,  and  is  usually  seen  in 
children  of  the  school  age,  especially  in  girls  at  puberty. 

Etiology. — Heredity  is  an  important  factor,  for  if  one  or  both^ 
parents  are  neurotic  there  is  likely  to  be  little  or  no  control  over  the 
offspring;  they  are  indulged  in  every  whim,  and  too  much  attention 
is  paid  to  minor  ailments,  and  the  imitative  disposition  of  the  child 
is  often  the  precursor  of  real  trouble.  Children  in  institutions  and 
asylums  who  receive  only  little  personal  attention  from  their  superiors 
are  often  the  victims  of  hysteria.  Morbid  sensations  and  psychical 
phenomena,  such  as  fear,  are  productive  of  attacks. 

Symptomatology. — The  attacks  do  not  present  any  great  varia- 
tion from  those  seen  in  adults.  The  tendon  reflexes  are  not  so  often 
found  exaggerated  and  disturbances  of  sensation  are  not  commonly 
observed.  It  would  be  impossile  to  describe  a  typical  case  of  hysteria, 
as  certain  groups  of  symptoms  are  in  evidence  in  one  case  and  entirely 
absent  in  another.  The  symptoms  are  traceable  to  defects  in  the 
various  body  functions,  symptoms,  and  organs. 

Sachs  classifies  the  symptoms  into  three  groups — psychic,  motor, 
and  sensory  manifestations  connected  with  vasomotor  disturbances. 


490  DISEASES  OF  CHILDREN. 

Under  the  first  group  are  the  weak-minded  children  with  a  per- 
verse will.  Hysterical  mania  may  manifest  itself  if  the  child's  wish  is 
opposed,  following  a  sudden  fright  or  even  a  fit  of  anger.  Alternate 
laughing  and  crying  with  kicking  or  tearing  of  objects  and  clothes 
occur,  while  the  disturbance  is  made  worse  by  attempts  to  console  or 
sympathize.  Hysteroepilepsy,  while  undoubtedly  extremely  rare  in 
children,  is  of  greater  importance  than  some  of  the  other  hysterical 
manifestations.  These  children  have  a  vicious  family  history,  in- 
cluding alcoholism,  insanity,  etc.  The  attacks  must  be  studied  and 
epilepsy  excluded  after  repeated  observations.  In  hystero-epilepsy 
there  is  no  aura.  The  bladder  and  rectal  functions  are  not  disturbed, 
the  attacks  are  of  longer  duration,  there  is  no  complete  loss  of  con- 
sciousness, personal  injury  is  rare,  and  the  movements  themselves  are 
tonic,  exaggerated,  and  often  purposeful. 

A  great  variety  of  hysterical  manifestations  may  be  seen:  those 
involving  only  the  lower  extremity  or  the  head  and  neck  alone.  The 
esophageal  spasm  is  not  rare  in  girls  at  puberty  (globus  hystericus). 

Sometimes  paralysis  follows  the  jactations  or  occurs  alone  as  a 
hysterical  manifestation.  Again,  only  certain  functions  may  be 
paralyzed.  Hysterical  aphonia  is  not  uncommon,  especially  in  insti- 
tutions and  asylums.  They  disappear  quite  suddenly  when  confidence 
is  established,  and  local  examination  reveals  a  normal  laryngoscopic 
picture.  Any  part  or  portion  of  the  body  may  be  affected.  The 
regional  paralysis  is,  moreover,  usually  associated  with  regional  anes- 
thesia. The  condition  of  the  reflexes  which  are  not  exaggerated  and 
the  absence  of  spasticity  in  the  muscles  and  the  unaltered  electrical 
reaction  serve  to  differentiate  it  from  the  true  forms.  Spasmodic 
conditions,  such  as  hiccough,  dysphagia,  anorexia,  and  vomiting,  some- 
times occur  and  may  be  extremely  troublesome.  Spasmodic  cough 
and  purposeless  screaming  are  especially  seen  in  young  girls.  Hyper- 
esthesia and  anesthesia  are  not  so  commonly  observed  as  in  adults, 
but  when  present  are  apt  to  distort  the  diagnosis  if  the  physician  is  not 
on  his  guard.  Disturbances  of  vision  especially  must  be  kept  in 
mind  in  this  relation.  Organic  lesions,  however,  should  be  carefully 
excluded  before  a  diagnosis  of  hysteria  is  made. 

Prognosis. — This  is  better  in  children  than  in  adults.  Relapses 
are  common  if  control  is  not  absolute. 

Treatment. — The  acute  attack  may  often  be  interrupted  in  child- 
ren in  the  ordinary  case  by  the  use  of  the  aromatic  spirits  of  ammonia, 
not  too  well  diluted,  or  by  giving  apomorphin  in  emetic  doses.  Cold 
douches,  when  unexpectedly  applied  to  the  face  and  chest  ma}''  arrest  the 
attack.    In  intractable  cases  the  rest  treatment  should  be  faithfullv  tried. 


GENERAL  NERVOUS  DISEASES.  491 

If  this  is  not  effective  a  change  of  environment  is  then  most  important. 
The  neurotic  parent  infiuences  the  child  not  only  through  the  inherently 
weak  nervous  system,  but  by  improper  training  and  defective 
example.  Sometimes  it  is  necessary  to  send  these  children  to  special 
schools  whose  principals  have  made  a  study  of  neurotic  children. 
Improvement  in  general  physique  is  always  to  be  aimed  at  and  is  at- 
tained by  aerotherapy  and  nutritious  plain  food.  The  dietary  should 
be  supervised  and  a  special  list  prepared  for  the  needs  of  the  particular 
child. 

The  suggestive  influence  of  the  physician  who  will  exert  his  force 
of  character  and  thus  establish  confidence  can  be  made  extremely 
powerful  in  its  effect,  and  often  produce  a  cure  alone.  Baths  and 
douches  have  a  distinctly  favorable  influence.  The  electrical  currents 
are  sometimes  useful  for  their  moral  effect.  Medicinal  measures  are 
rarely  necessary  if  the  above  plan  is  feasible  and  strictly  adhered  to. 

Epilepsy. 

Epilepsy  is  a  disease  often  occurring  in  early  life,  and  character- 
ized by  seizures  which  vary  in  their  intensity,  affecting  only  a  portion 
of  the  body,  or  they  are  generalized. 

Etiology. — The  children  of  neurotic  parents,  those  who  have 
themselves  been  afflicted  with  epilepsy,  hysteria,  chorea,  and  similar 
nervous  diseases,  may  fall  victims  to  this  disease.  To  these  may  be 
added  syphilis  and  alcoholism.  Traumatism  during  or  after  birth  and 
maldevelopment  of  the  brain  as  a  result  of  acute  infective  processes 
may  later  lead  to  epileptic  seizures. 

Among  the  exciting  causes  the  intestinal  toxemias,  visual  defects 
and  obstructive  growths  in  the  respiratory  tract,  such  as  adenoids  and 
polypi,  may  be  mentioned. 

Symptomatology.  Petit  Mai. — In  this  form  there  may  at  inter- 
vals occur  momentary  periods  of  unconsciousness.  The  child  may 
suddenly  cease  playing  or  speaking  and  stare  into  vacancy.  The 
parents  may  bring  the  child  to  the  physician  complaining  of  its  "  faint- 
ing attacks."  If  questioned,  the  child  has  no  recollection  or  knowl- 
edge of  these  periods.  If  seen  at  the  time  of  an  attack,  the  pupils  of 
the  eyes  may  be  seen  to  suddenly  dilate  and  the  face  turn  pale.  Occa- 
sionally there  is  a  period  of  drowsiness  or  the  child  seems  dazed  and  is 
not  willing  to  immediately  resume  its  former  occupation. 

Grand  Mai. — There  is  no  sharp  limit  between  the  mild  and  the 
severe  forms.  Grand  mal  is  spoken  of  if  there  is  an  aura,  a  period  of 
unconsciousness,  a  convulsion,  and  the  involuntary  passage  of  urine 


492  DISEASES  OF  CHILDREN. 

and  feces.  It  should  be  recollected  that  young  children  may  not  have 
an  aura  or  may  be  incapable  of  interpreting  it.  Intelligent  parents 
may  sometimes  foresee  a  coming  attack  by  noting  a  change  in  the  child's 
disposition  or  by  observing  certain  unusual  bodily  movements.  The 
sensation  may  be  felt  in  the  different  situations,  as  the  stomach,  the 
eyes,  or  noises  in  the  ears. 

The  child  suddenly  falls  into  unconsciousness  and  a  convulsive 
seizure  takes  place  simulating  the  ordinary  eclamptic  seizures  de- 
scribed on  page  485.  Sometimes  an  initial  cry  precedes  the  fall.  The 
dilated  pupils  do  not  react  to  light,  the  tongue  may  be  bitten,  and  blood- 
stained saliva  may  appear  at  the  mouth,  although  this  is  not  usual  in 
childhood.  After  a  few  minutes  the  spasm  relaxes  and  the  patient  is 
found  to  have  involuntarily  passed  his  urine  or  even  emptied  the 
rectum.  Following  the  return  to  consciousness,  the  patient  is  in  a 
semicomatose  or  stupid  condition,  complains  of  headache,  and  often 
drops  into  a  restless  sleep.  Nocturnal  attacks  may  be  discovered 
only  by  the  bitten  tongue  or  drowsiness  on  the  succeeding  day.  The 
"epileptic  voice  sign"  of  Clark  and  Scripture  may  excite  suspicion  in 
the  medical  attendant.  It  is  described  as  a  monotonous  voice,  the 
melody  proceeding  by  even  steps  and  occurs  in  this  disea  e  alone. 

Diagnosis. — Hysteria  is  differentiated  from  epilepsy  by  the  ab- 
sence of  entire  loss  of  consciouneess,  the  stage  of  excitation  with  laugh- 
ing and  crying,  and  by  the  absence  of  dilated  pupils  and  involuntary 
urination  and  defecation.  Tumors  of  the  brain  may  affect  localized 
regions;  they  may  have  peculiarities  of  gait  and  changes  in  the  fundus 
of  the  eye. 

Prognosis. — The  gravity  is  determined  to  a  great  extent  by  the 
age.  The  earlier  the  seizures  appear  the  poorer  the  prognosis.  Fre- 
quent recurrences  of  well-marked  attacks  are  less  hopeful  and  may  be 
followed  by  feeble-mindedness. 

Treatment. — During  the  attack  the  child  should  be  placed  in  bed 
and  guarded  against  personal  injury.  Little  or  no  food  should  be 
offered  after  the  attack  until  the  period  of  drowsiness  is  past.  The 
diagnosis  once  established,  stringent  prophylactic  measures  should 
be  instituted  to  prevent  recurrences.  A  life  in  a  quiet  country  dis- 
trict with  an  unusual  amount  of  sleep  and  little  mental  exercise  is  dis- 
tinctly beneficial.  A  diet  consisting  of  simple  food  (coffee  and  tea 
being  absolutely  excluded),  with  plenty  of  vegetables  and  fresh  fruits 
to  insure  daily  bowel  activity,  is  required.  For  the  children  of  the 
poor,  life  in  the  epileptic  colonies,  where  the  children  conform  to  a 
certain  routine  adds  much  to  their  chances  of  improvement. 

The  bromids  when  administered  in  divided  doses,  five  grains  for 


GENERAL  NERVOUS  DISEASES.  493 

a  five-year-old  child  three  or  four  times  a  day,  while  not  curative,  serve 
to  reduce  the  number  of  attacks.  When  the  latter  occur  at  night  only, 
it  is  best  to  administer  one  large  dose,  about  twenty  grains,  at  bedtime. 
This  drug  should  be  given  to  the  point  of  toleration  and  resumed  after 
a  period  of  rest. 

Headaches. 

Headache  is  a  symptom  deserving  of  especial  attention  since  it 
may  be  symptomatic  of  many  functional  or  even  organic  disorders. 

Etiology. — It  most  frequently  results  among  children  from  gastric 
or  intestinal  disturbances  and  from  eye-strain.  Anemic  children  who 
have  been  improperly  fed  and  who  are  forced  into  competition  with 
their  schoolmates  often  suffer  from  toxic  headaches.  If  the  child 
remains  in  badly  ventilated  or  superheated  rooms  frontal  headaches 
frequently  result.  The  cause  may  be  more  obscure  and  may  be 
found  to  result  directly  or  indirectly  from  adenoids,  ear  disease,  neph- 
ritis, cardiac  disease,  and  malarial  poisoning.  Young  girls  at  the 
beginning  of  the  menstrual  period,  especially  if  they  are  neurasthenic, 
may  complain  of  frequent  headaches.  Many  of  the  acute  infectious 
diseases  are  preceded  by  cephalgia  as  a  prodromal  symptom.  Men- 
ingitis and  tumors  of  the  brain  cause  persistent  headaches  which  are 
referred  to  one  area. 

Migraine  or  sick  headache  occurs  in  older  children.  It  is  usually 
unilateral  in  character  and  preceded  by  nausea  and  vomiting  and  dis- 
turbances of  vision. 

Diagnosis. — The  diagnosis  depends  upon  a  careful  physical  ex- 
amination to  exclude  organic  disease,  and  in  obscure  cases  of  this 
type  lumbar  puncture,  the  opthalmoscope  and  the  tuberculin  tests 
may  be  necessary.  Functional  headaches  when  dependent  upon 
intestinal  derangements  are  accompanied  by  a  coated  tongue,  a  fetid 
breath,  and  constipation.  Those  due  to  anemia  and  general  asthenia 
exhibit  pallor  of  the  mucous  membranes,  lassitude,  and  depression.  In 
these  cases  a  blood  examination,  at  least  the  Talquist  hemoglobin 
estimation,  should  be  made.  Headaches  due  to  visual  errors  begin 
or  are  intensified  at  the  end  of  the  school  day  or  whenever  the  eyes 
have  been  overtaxed.  An  examination  with  the  test  cards  (see  p.  573) 
should  be  made  as  a  matter  of  routine,  as  a  more  detailed  ocular 
examination  may  then  disclose  astigmatism  or  other  refractive  errors. 

The  diagnosis  of  migraine  depends  upon  the  periodic  unilateral 
attacks  and  the  accompanying  nausea  and  eye  disturbances. 

Treatment. — This  is  directly  dependent  upon  the  cause.  When 
the  headache  is  the  result  of  digestive  errors  acute  attacks  may  be 


494  DISEASES  OF  CHILDREN. 

relieved  by  clearing  out  the  intestinal  tract  and  prescribing  a  proper 
dietary  which  is  to  be  strictly  followed.  Anemic  headaches  are  cured 
by  life  in  the  open  air  or  at  least  an  abundance  of  fresk  air  and  sun- 
shine in  the  rooms  which  the  child  occupies.  Reducing  the  number 
of  study  hours  and  prohibiting  special  studies  after  school  hours  may 
alone  be  sufl&cient.  Obstructions  in  the  respiratory  tract  and  errors 
of  refraction  must  be  removed  before  any  progress  can  be  made. 

A  child  suffering  with  migraine  should  be  put  to  bed  in  a  quiet 
dark  room,  during  the  attack,  and  analgesics,  as  phenacetin  combined 
with  cafifein  or  the  bromids,  may  be  given.  A  hot-water  bag  or  light 
massage  over  the  forehead  and  temporal  regions  may  be  agreeable. 
Future  attacks  must  be  prevented  by  strict  regulation  of  the  child's 
life  and  diet. 

Insomnia. 

This  symptom  which  occurs  in  infancy  and  childhood  generally 
results  from  some  functional  derangement  which  can  usually  be 
removed  when  once  recognized. 

The  infant  and  child  are  dependent  upon  a  sufficient  amount  of 
sleep  to  promote  healthy  growth.  That  it  cannot  or  does  not  spend 
sufficient  hours  in  sleep  may  be  due  to  acute  physical  discomfort  or 
from  a  perversion  of  its  natural  habits  resulting  from  mismanagement 
on  the  part  of  its  attendants. 

The  following  table  will  give  a  general  idea  of  the  daily  amount 
of  sleep  required  in  early  life: 

Healthy  new-born,  20  hours,  minimum  16  hours. 

Six  months,  16  hours  (2  naps). 

One  to  three  years,  12  hours  (and  one  nap). 

Three  to  six  years,  12-10  hours. 

Six  to  ten  years,  10-8  hours. 

When  the  infant  is  unable  to  approximate  the  normal  amount  of 
sleep  a  careful  examination  of  its  mode  of  life  should  be  made  followed 
by  a  systematic  physical  examination.  Among  the  more  frequent 
causes  of  sleeplessness  are  digestive  disturbances,  undue  excitement, 
bad  hygienic  conditions,  and  localized  pain.  Physical  examination 
may  show  that  the  child  is  suffering  from  an  otitis,  skin  lesions,  en- 
larged tonsils,  adenoids,  rachitis,  extreme  anemia,  or  the  disease  may 
be  organic,  such  as  meningitis  or  incipient  disease  of  the  brain  or  spinal 
cord. 


GENERAL  NERVOUS  DISEASES.  495 

Treatment. — When  the  cause  is  found  efforts  should  be  made  to 
remove  or  correct  it  before  any  other  measures  are  undertaken.  A 
careful  regulation  must  be  made  of  the  child's  daily  life,  not  omitting 
what  may  seem  to  be  minor  influences  bearing  upon  its  sleeplessness. 
A  well-ventilated,  cool,  darkened  room  should  be  provided,  which  the 
infant  or  child  should  occupy  alone;  the  bed  clothing  should  be  light 
and  not  too  warm.  The  evening  meal  must  be  simple,  not  containing 
too  much  liquids.  Reading  of  exciting  stories  to  children  should  be 
prohibited.  These  changes  with  an  outdoor  life  are  often  sufficient 
to  correct  insomnia. 

If  a  high  temperature  is  the  cause  of  the  insomnia,  baths  or  spong- 
ing with  alcohol  will  often  promote  sleep.  If  temporarily  any  of  the 
hypnotics  are  necessary,  the  bromids,  in  doses  of  one  and  a  half  grains 
for  each  year  of  age,  or  one  grain  of  veronal  for  a  two-year-old  child 
will  produce  the  desired  effect.  The  bromids  combined  with  chloral 
hydrate  are  effective  in  older  neurotic  children,  especially  if  they 
also  have  night  terrors. 


Pavor  Nocturnus. 

(Night  Terrors.) 

This  condition  occurs  in  children  who  have  in  some  manner  unduly 
excited  their  nervous  system.  They  may  or  may  not  be  the  children  of 
neurotic  parents.  Children  from  the  third  to  the  eighth  year  are  more 
commonly  subject  to  night  terrors.  In  our  experience  the  condition 
appears  with  the  greatest  frequency  at  the  beginning  of  school  life 
when  unaccustomed  responsibilities  must  suddenly  be  assumed.  The 
reading  of  unnatural  stories  so  often  practised  by  nurses  or  unusual 
and  grotesque  sights,  as  in  the  circus,  may  induce  an  attack.  A 
heavy  meal  just  before  retiring  may  also  be  a  cause. 

The  children  awake  suddenly,  usually  before  the  midnight  hour, 
and  cry  out,  exhibiting  signs  of  fright  or  terror.  They  are  soothed 
with  difficulty  and  can  give  no  explanation  of  their  sudden  awakening 
or  dream.  If  questioned  in  the  morning  they  remember  nothing  of 
the  occurrence.  The  terrors  may  repeat  themselves  several  times  in 
a  week,  but  they  seldom  occur  twice  in  the  same  night.  When  the 
cause  is  removed  the  recurrences  become  more  infrequent  and  finally 
disappear  altogether. 

Treatment. — Every  effort  should  be  made  to  decrease  the  ner- 
vous excitability  of  the  child  by  prohibiting  school  work  at  all  for  a 
time  or  decreasing  the  number  of  school  hours.     At  home  no  supple- 


496  DISEASES  OF  CHILDREN. 

mentary  teaching  should  be  allowed  and  association  with  older  minds 
not  encouraged.  A  healthy  amount  of  physical  tire,  rather  than 
mental  strain  should  be  the  desideratum.  The  evening  meal  particu- 
larly should  consist  of  light  and  easily  digested  articles,  and  should 
be  eaten  at  least  an  hour  before  retiring.  If  these  measures  are 
carried  out  it  will  rarely  be  necessary  to  give  bromids  or  hypnotics. 

Tetany. 

(Tetanilla;  Arthrogryposis.) 

Tetany  is  a  neurotic  disorder  characterized  by  intermittent 
or  constant  tonic  spasms  of  the  muscles  of  the  upper  and  lower 
extremities. 

Etiology. — The  disorder  is  dependent  upon  the  absorption  of 
toxic  products  which  readily  affect  the  highly  sensitive  nervous 
system  of  early  life.     It  occurs  most  frequently  from  the  sixth  month 


Fi3.  131. — Tetany,  with  characteristic  positions  of  hands  and  feet. 


to  the  end  of  the  second  year.  We  would  give  rachitis  the  first  place 
in  the  role  of  etiologic  factors,  and  the  conditions  which  may  produce 
this  disease  may  also  produce  tetany.  This  is  further  borne  out 
by  the  fact  that  convulsions  and  laryngismus  stridulus  frequently 
occur  in  those  subject  to  tetany.  It  also  results  from  intestinal 
or  peripheral  irritation  and  may  follow  exhausting  diseases  or 
secondary  pneumonias. 

Symptomatology. — The  condition  begins  without  any  warning  in 
infancy,  although  older  children  sometimes  complain  or  give  evidence 


GENERAL  NERVOUS  DISEASES.  497 

of  an  itching  or  tingling  sensation.  Attention  is  generally  called  to 
the  condition  by  the  muscular  contractions  of  the  hands  and  feet.  A 
close  examination  will  show  that  the  arms  are  held  quite  closely  to  the 
chest,  the  forearms  being  partly  flexed  on  the  arms  and  the  hand 
flexed  at  the  wrist,  while  the  fingers  may  either  be  tightly  closed  over 
the  inverted  thumb  on  the  palm,  simulating  the  driving  position,  or 
they  may  be  hyperextended  and  held  closely  together  like  the  obstetric 


P"iG.  132. — Tetany. 

hand.  In  the  low^er  extremities  the  thighs  may  be  drawn  up  onto 
the  abdomen  and  the  legs  flexed  on  the  thighs;  some  degree  of  adduc- 
tion of  the  thighs  is  generally  present.  The  foot  itself  is  extended  or 
hyperextended,  and  the  toes  are  flexed.  The  position  of  talipes  equino- 
varus  being  often  assumed.  We  have  also  noted  spasticity  of  the 
erector-spinae  group  of  muscles,  so  that  the  child  could  be  raised  by 
the  head  retaining  an  erect  posture.  The  child's  expression  is  one  of 
discomfort.  Pain  is  elicited  if  attempts  are  made  to  replace  the  ex- 
32 


498  DISEASES  OF  CHILDREN. 

tremities  in  their  natural  positions.  There  is  rarely  any  temperature 
which  can  be  attributed  to  the  condition  itself  and  the  mentality  is 
not  affected.  After  a  variable  time,  sometimes  a  few  days  or  it  may  be 
weeks,  the  contractures  intermit  and  the  so-called  latent  period  may  be 
entered  into,  in  which  there  is  weakness  and  some  slight  spasticity  of 
the  affected  muscle  groups,  or  the  symptoms  may  never  return.  In 
this  disease  certain  phenomena  may  be  elicited  which  are  distinctly 
helpful  in  making  or  confirming  a  diagnosis. 

Trousseau' s  symptom  can  be  produced  in  the  latent  period  by 
pressing  upon  the  main  nerves  and  arteries  of  the  extremities.  In  this 
way  a  characteristic  paroxysm  can  be  produced  which  ceases  when  the 
pressure  is  removed. 

Erb's  symptom  is  dependent  upon  the  increased  electrical  excita- 
bility in  the  peripheral  nerves,  muscular  contractions  being  produced 
even  by  weak  cuprents. 

Chvostek's  symptom  is  a  facial  phenomenon  which  is  of  value  if 
obtained  in  conjunction  with  the 'others  and  is  elicited  by  pressing  the 
finger  or  any  other  blunt  object  over  the  facial  nerve  when  contrac- 
tions immediately  occur. 

Differential  Diagnosis. — From  tetanus  it  may  be  distinguished 
by  the  absence  of  trismus  which  is  an  early  symptom,  by  the  lack  of 
fever,  by  the  intermittent  attacks,  and  the  ability  to  elicit  Trousseau's, 
Erb's,  and  Chvostek's  signs.  Cerebrospinal  meningitis  is  distinguished 
by  the  presence  of  high  irregular  temperature,  cerebral  signs,  and  by 
lumbar  puncture. 

Prognosis. — The  prognosis  is  mainly  dependent  upon  the  under- 
lying cause.  In  itself  it  rarely  endangers  life  except  by  predisposing 
to  convulsive  seizures. 

Treatment. — The  underlying  condition  must  be  carefully  sought 
for  and  treatment  immediately  directed  toward  its  removal.  It  is  a 
safe  rule  to  thoroughly  empty  the  bowels  by  the  use  of  a  large  dose  of 
castor  oil  or  calomel.  An  enema  may  be  given  for  immediate  relief. 
The  stools  should  be  kept  for  the  physician's  examination,  as  he  may 
therein  find  the  source  of  the  peripheral  irritation,  such  as  badly  digested 
food  or  intestinal  parasites.  Baths  at  a  temperature  of  110°F.  may 
be  given  two  or  three  times  during  the  day  for  their  relaxing  effect. 
In  severe  cases  a  mixture  of  chloral  hydrate  and  the  bromid  of  soda 
can  be  injected  into  the  rectum.  In  the  latent  period  dietetic  meas- 
ures should  be  coupled  with  most  favorable  hygienic  conditions.  The 
food  ordered  must  be  such  as  to  overcome  the  rachitic  manifestations 
if  present  (see  page  432),  or  produce  an  increase  in  weight  if  the  neuro- 
sis has  resulted  from  an  exhausting  disease. 


GENERAL  NERVOUS  DISEASES.  499 

Myotonia  Congenita. 
{Thomsen' s  Disease.) 

Myotonia  congenita  is  a  rare  disease,  mainly  hereditary,  charac- 
terized by  a  sudden  rigidity  of  certain  muscle  groups  when  a  voluntary 
movement  is  attempted. 

Etiology. — The  disease  may  occur  early  in  childhood,  but  the 
greatest  number  of  cases  are  seen  between  the  fifteenth  and  twenty- 
fifth  year.  Thomsen  believes  it  to  be  a  hereditary  disease;  five 
generations  in  his  own  family  having  been  so  afflicted.  Inclement, 
cold  weather  and  emotional  states  may  bring  on  the  attacks. 

Symptomatology. — The  muscular  contractions  develop  when  the 
patient  attempts  some  voluntary  act,  as  rising  from  bed  or  from  a 
chair.  The  muscular  spasm  prevents  the  completion  of  this  effort,  and 
repeated  attempts  are  necessary  before  it  is  accomplished.  These 
inhibited  efforts  in  a  child  otherwise  well  developed  are  striking 
enough  to  fix  the  diagnosis.  If  a  sharp  blow  is  given  over  a  muscle, 
a  tonic  contraction  occurs  which  persists  for  some  time.  Erb  has 
shown  that  the  muscles  react  peculiarly  to  electrical  stimuli.  This 
"myotonic  reaction,"  as  he  calls  it,  is  a  valuable  confirmatory  sign. 
Faradic  currents  stimulate  the  muscles,  producing  wavy,  rhythmical 
long-continued  contractions.  The  same  effect  may  be  produced  by 
the  galvanic  current. 

Diagnosis. — The  disease  is  distinguished  from  tetany  by  the  con- 
tractions produced  by  mechanical  stimulation  and  by  the  peculiar 
electrical  reaction  (Erb's  myotonic  reaction).  Furthermore,  there 
is  no  increase  in  mechanical  excitability  by  pressure  over  the  nerve 
or  vessel  trunks  as  in  tetany.  Congenital  paramyotonia  (Eulen- 
berg's  modification)  may  be  differentiated  by  the  absence  of  the  myo- 
tonic electric  reaction  and  also  of  any  increase  in  the  mechanical 
excitability. 

Treatment. — Thomsen  noted  that  the  symptoms  appeared  less 
often  the  greater  the  muscular  activity  of  the  patient;  he  therefore 
advised  a  life  which  would  necessitate  a  constant  use  of  the  muscles. 

Paramyoclonus  Multiplex. 

This  disease,  although  very  rare  in  early  life,  is  mentioned  here 
mainly  for  the  purposes  of  differential  diagnosis.  It  is  character- 
ized by  the  production  of  repeated  momentary  clonic  spasms  affecting 
a  certain  muscle  or  groups  of  muscles  which  are  usually  symmetrically 
involved.     The  muscles  of  the  face  are  rarely  involved.     A  slight  tre- 


500  DISEASES  OF  CHILDREN. 

mor  of  the  muscles  may  be  observed  between  the  attacks  which  usually 
follow  some  strong  emotional  excitement  or  physical  effort. 

The  myotonic  reaction  is  rarely  increased  and  no  change  in  elec- 
trical excitability  is  noticed. 

Treatment. — We  are  almost  powerless  to  effect  a  cure  in  this  dis- 
ease, although  amelioration  of  the  symptoms  is  possible  by  the  use  of 
sedative  baths,  mild  gymnastic  exercises,  and  a  life  free  from 
excitement. 

Angioneurotic  Edema. 

(Acute  Circumscribed  Edema.) 

This  is  a  vasomotor  disturbance,  trophic  in  origin,  characterized 
by  attacks  of  circumscribed  edematous  areas  on  the  body. 

Gastrointestinal  intoxication  is  the  most  frequent  cause  in  chil- 
dren, although  it  sometimes  appears  without  any  discoverable  reason. 
The  edema  may  be  well-marked  a  few  hours  after  its  inception  and  may 
just  as  suddenly  disappear,  only  to  reappear  in  some  other  portion  of 
the  body.  There  are  no  marked  constitutional  symptoms,  the  chil- 
dren simply  complaining  of  the  itching  or  the  discomfort  caused  by 
the  edema  when  it  affects,  for  example,  the  face. 

In  a  recent  case  seen  by  one  of  us  there  were  unquestionable 
signs  of  edema  of  the  lungs,  which  appeared  suddenly,  and  cleared  up 
within  forty-eight  hours.  The  area  affected  is  raised,  pale  in  the 
center,  with  an  irregular  bluish-red  margin,  differing  from  the  other 
edemas  in  that  it  does  not  pit  on  pressure.  Fatal  cases  have  been  re- 
ported in  which  the  larynx  and  pharynx  were  affected. 

Treatment. — Special  treatment  during  the  attack  is  hardly  neces- 
sary. Compresses  wrung  out  of  warm  boric  acid  solution  are  soothing 
to  the  patient.  A  saline  purge  should  be  given  and  future  attacks 
inhibited  by  scrupulous  attention  to  the  dietary. 

Tics. 

A  tic  is  the  unconscious  activity  of  a  group  of  voluntary  muscles 
resembling  a  purposeful  movement,  its  frequent  repetition  classing  it 
as  a  habit. 

They  occur  most  frequently  in  children  from  the  fifth  to  the 
fourteenth  year  of  life.  An  underlying  neurotic  element  can  usually 
be  found  in  the  patient  or  he  has  been  trained  under  attendants  who 
by  their  management  have  not  developed  his  self-control.  These 
neurasthenic  children  may  easily  develop  a  tic  from  some  primary 


GENERAL  NERVOUS  DISEASES.  501 

source  of  irritation,  as  foreign  objects  or  growths  in  the  air  passages  or 
eyes,  skin  diseases,  as  eczema,  phimosis,  or  even  chorea.  They  may 
arise  from  emotional  disturbances  or  as  a  result  of  imitation  as  pointed 
out  by  Scripture  in  children  of  unstable  and  willful  disposition.  The 
most  common  tic  is  the  one  involving  the  muscles  about  the  eye  in 
which  the  child  rapidly  winks  the  eye-lid  several  times  in  succession. 
This  occurs  at  short  intervals  during  the  day.  Not  unlike  these  in 
motor  characteristics  are  the  tics  affecting  the  face,  scalp,  ears,  tongue, 
neck,  and  extremities.  When  tics  are  accompanied  by  mental 
disturbances,  a  child  otherwise  rational  may  repeat  words  or  phrases 
of  an  obscene  character  without  provocation  or  regard  to  the  time  and 
place.     This  is   known  as  coprolalia. 

Differential  Diagnosis. — Tics  may  be  distinguished  from  chorea 
by  the  purposive,  systematic  nature  of  the  movements  which  occur 
at  intervals.  The  spasms  of  paramyoclonus  multiplex  affect  only  a 
certain  muscle  and  are  not  controlled  by  fixing  the  attention.  Habit 
spasms  resemble  normal  movements,  but  differ  from  them  in  that 
they  are  unnecessary.  They  are  unlike  tics  in  that  they  are  not  con- 
vulsive in  type. 

Stuttering  and  Stammering  (Hyperphonia). — In  this  connection 
another  class  of  tics  forming  a  large  part  of  the  speech  defects  of  child- 
hood may  be  considered.  Scripture  defines  hyperphonia  as  a  psycho- 
motor neurosis  or  a  mental  tic  or  habit  over  which  the  patient  has  no 
control  and  which  is  the  result  of  a  compulsive  idea  connected  with 
speaking.  A  neurotic  child  may  acquire  the  habit  by  imitating  others 
or  he  may  have  some  defect  connected  with  his  respiratory  apparatus. 

The  symptoms  have  been  divided  into  spasms  and  hypertonicity, 
affecting  the  respiratory,  laryngeal,  and  articulatory  muscles;  to  these 
are  sometimes  added  facial  and  bodily  tics. 

Treatment. — A  careful  physical  examination,  including  the  special 
organs,  and  an  inquiry  into  the  details  of  the  child's  life  should  be  made 
in  every  case.  An  underlying  and  neglected  cause  may  be  found  in 
refractive  errors,  abnormalities  in  the  nose,  ears,  or  teeth.  Peripheral 
irritation  from  any  source  must  be  removed;  while  this  is  not  curative, 
it  is  conducive  to  a  more  rapid  recovery  and  prevents  recurrences. 
The  physical  condition  of  the  child  should  be  improved  by  nutritious 
food,  tonic  baths,  ample  amount  of  sleep,  and  a  routine  life  under  judi- 
cious discipline.  A  change  of  environment  will  often  make  the  spe- 
cial treatment  much  more  effective.  Fowler's  solution  may  often 
be  given  wdth  benefit.  In  a  number  of  our  cases  the  method  advocated 
by  Scripture  was  remarkably  effective.  It  depends  upon  the  volun- 
tary imitation  of  his  own  act  by  which  the  child  is  trained  to  a  con- 


502  DISEASES  OF  CHILDREN. 

scious  performance  of  the  tic.  In  this  way  he  is  encouraged  and  en- 
abled finally  to  inhibit  the  act.  The  child  looks  into  a  mirror  and  is 
directed  to  imitate  five  times  in  succession  his  own  tic  when  it  appears. 
At  first  the  imitation  is  a  poor  one,  but  improves  with  practice,  until 
finally  complete  control  is  obtained. 

Scripture's  method  for  stuttering  and  stammering  consists  in 
introducing  melody  into  the  monotone  voice  of  the  stutterer.  The 
child  is  directed  to  repeatedly  sing  a  line  of  some  familiar  song;  he 
is  then  taught  to  speak  a  sentence  in  the  same  sing-song  fashion. 
In  this  way  the  monotone  voice  is  finally  abandoned  and  cadences 
and  inflections  are  introduced.  The  "melody  cure"  is  founded 
upon  the  fact  that  a  stutterer  never  stutters  when  he  sings.  This 
simple  treatment  is  elaborated  by  encouraging  the  child  in  forms  of 
elocution  and  graceful  mannerisms. 

Finally,  in  some  cases  it  is  also  necessary  to  distract  the  mind 
when  the  patient  starts  to  speak;  this  is  done  by  teaching  him  to  beat 
time  in  a  quick,  vigorous  manner  as  he  starts  to  speak  or  to  set  him- 
self off  by  repeating  one,  two,  and  starting  off  to  speak  on  three.  These 
lessons  are  given  at  first  three  times  a  week  for  half-hour  periods, 
the  time  and  interval  being  lessened  as  progress  is  made. 


CHAPTER  XXXVIL 

DISEASES  OF  THE  PERIPHERAL  NERVES. 

Multiple  Neuritis. 

Definition. — An  inflammation  of  the  peripheral  nerves,  in  some  of 
which  there  is  a  tendency  to  acute  degenerative  changes.  It  may- 
affect  several  nerves,  usually  symmetrically,  or  it  may  be  general. 

Etiology. — Bacteria  or  at  least  bacterial  toxins  in  all  probability 
cause  the  disease.  The  infectious  diseases,  especially  measles,  malaria, 
influenza,  typhoid,  and  tuberculosis,  may  be  followed  by  a  polyneuritis, 
but  it  is  a  rare  complication,  with  the  exception  of  diphtheria.  Some- 
times exposure  or  cold  and  rarely  alcohol,  arsenic,  or  lead  cause  the 
disease.  Alcohol  must  be  considered  as  a  factor  in  treating  the  chil- 
dren of  our  foreign  population. 

Pathology. — There  is  an  inflammation  of  the  affected  nerve,  inter- 
stitial or  parenchymatous  in  character,  followed  by  more  or  less  com- 
plete degeneration  of  the  fibers.  The  appearance  of  the  nerve  at 
first  is  that  of  an  acute  inflammatory  nature,  with  swelling,  hyperemia,, 
and  minute  hemorrhages  in  the  nerve  sheaths.  Later  degenerative 
changes  in  the  nerve  fibers  only  are  seen.  The  muscles  undergo  paren- 
chymatous or  even  interstitial  changes. 

Symptomatology. — The  onset  may  be  sudden,  with  a  chill  or  a 
convulsion  and  fever;  as  a  rule,  however,  it  is  gradual.  The  mother 
may  notice  that  the  child  is  unable  to  properly  support  itself  on  its 
feet;  if  forced  attempts  to  walk  are  made  the  child  stumbles  or  sinks 
to  the  floor.  After  a  few  days  or  sometimes  within  a  few  hours  there 
is  intense  pain  on  handling.  The  child  cries  when  approached,  fearing 
the  pain  of  motion.  Occasionally  the  sensitiveness  along  the  course  of 
the  nerve  may  be  elicited.  Paralysis  now  follows  the  muscular  weak- 
ness and  it  progresses  symmetrically.  The  child  may  continually 
moan  or  cry  out  with  the  pain,  but  does  not  refuse  its  food.  Foot-drop 
and  wrist-drop  develop,  and  the  muscular  contractions  may  cause  de- 
formities. Tendon  reflexes  are  abolished  altogether,  or  at  least  dimin- 
ished, and  the  reaction  to  the  galvanic  current  is  slow.  Muscular 
atrophy  develops,  but  is  not  marked. 

Diagnosis. — The  history  of  an  antecedent  disease  or  a  distinct 
casual  factor,  as  alcohol,  may  be  suggestive  when  pain  and  paralysis 
ensue.     The  association  of  motor  and  sensory  symptoms  or  paralysis 

503 


504  DISEASES  OF  CHILDREN. 

along  anatomical  lines  and  the  changed  electrical  reaction  should 
cause  no  confusion.  When  there  is  lordosis  present  from  involvement 
of  the  muscles  of  the  back,  it  may  be  mistaken  for  Pott's  disease,  but 
the  deformity  is  not  angular  and  the  position  assumed  will  differen- 
tiate it. 

Course  and  Prognosis. — Cases  with  sudden  onset  in  which  the 
electrical  reaction  is  rapidly  changed  and  in  which  atrophy  occurs 
early  are  not  favorable  for  recovery.  The  average  case  begins  to  im- 
prove after  the  first  month,  recovery  generally  being  complete  in 
three  months.  The  sensory  symptoms  clear  up  first,  then  the  reflexes 
are  obtained.  In  some  cases  the  paralysis  may  be  permanent.  In- 
volvement of  certain  nerves,  as  the  vagus,  or  intercurrent  diseases  may 
bring  on  a  fatal  issue. 

Treatment. — If  the  disease  is  due  to  a  drug  or  alcohol  poisoning 
this  must  be  stopped  at  once  and  eliminatives  given.  An  initial 
dose  of  calomel  is  always  in  order.  The  child  should  be  placed  in  a 
comfortable  attitude  the  limbs  encased  in  cotton  wool  and  lying  on  a 
down  pillow.  The  pain  should  be  controlled  by  analgesics,  such  as 
the  bromids,  phenacetin,  or  even  codein  if  necessary  for  one  or  two 
doses.  Rest  and  hot  applications  during  the  onset,  and  later  massage 
and  vibratory  treatment  as  it  is  given  in  infantile  spinal  paralysis  is 
effective.  If  the  extremities  are  kept  in  a  proper  position  while  the 
disease  is  in  progress,  deformities  are  not  likely  to  result  and  ortho- 
pedic appliances  will  not  be  necessary. 

Diphtheritic  Paralysis. — This  is  a  form  of  multiple  neuritis  worthy 
of  special  note.  It  is  the  most  common  cause  in  early  life  and  affects 
for  the  most  part  only  one  region,  this  is  the  palate.  We  do  not  meet 
with  the  condition  as  frequently  since  antitoxin  has  come  into  general 
use.  It  is  less  likely  to  follow  if  the  diphtheria  has  been  recognized 
early  and  the  child  injected  with  the  serum  at  once.  We  have,  how- 
ever, seen  a  fatal  issue  in  cases  that  were  considered  extremely  benign 
and  in  which  the  prognosis  was  excellent.  Children  under  two  years 
of  age  are  rarely  affected.  Malignant  laryngeal  cases  are  more  sus- 
ceptible of  involvement.  It  sometimes  occurs  during  the  active  process, 
but  usually  it  appears  in  the  third  or  fourth  week  of  convalescence. 

Symptomatology. — Inability  to  swallow  well  with  regurgitation 
of  fluids  through  the  nose  or  a  peculiar  nasal  twang  in  the  voice  may 
first  attract  attention.  The  eyes  may  next  show  the  paralysis,  and 
if  this  is  more  extensive  the  lower  extremities  are  affected,  followed 
by  similar  changes  in  the  arms  and  the  muscles  of  the  trunk.  Ex- 
amination of  the  throat  will  easily  disclose  a  paresis  of  the  pharynx 
and  soft  palate;  it  is  relaxed,  flabby,  and  does  not  take  part  in  the 


DISEASES  OF  THE  PERIPHERAL  NERVES.  505 

acts  of  speaking  or  swallowing.  Closer  examination  of  the  eyes  shows 
weakness  of  the  ciliary  muscles,  the  pupil  reacting  sluggishly  and 
causing  defective  vision.  When  the  external  ocular  muscles  are 
paralyzed,  strabismus  results. 

Following  the  laryngeal  cases  the  loss  of  voice  is  particularly 
marked  and  persistent,  and  if  the  paralysis  occurs  during  the  intubation 
period  difficulty  may  be  experienced  in  keeping  the  tube  in  place. 
Recovery  is  the  general  rule;  fatal  cases  resulting  from  the  involve- 
ment of  the  vagus,  or  from  aspiration  pneumonia  when  the  epiglottis 
is  involved.  The  course  depends  upon  the  extent  of  the  paralysis  and 
the  regional  involvement.  The  average  case  requires  two  months  for 
recovery.  The  muscles  of  the  eyes  and  the  palate  recover  much  more 
quickly  than  the  muscles  of  the  extremities.  Weakness  of  the  back 
and  inability  to  properly  support  the  head,  with  the  loss  of  the  reflexes, 
may  persist  for  months. 

Treatment. — Rest  in  bed  and  close  observation  should  be  insisted 
upon  when  the  first  symptoms  of  paralysis  appear.  The  manage- 
ment will  depend  upon  the  extent  of  the  regional  involvement.  Cer- 
tain cases  in  which  there  is  only  aphonia  or  partial  paralysis  of  the 
palate  will  require  no  special  treatment,  but  the  heart  in  all  cases 
should  be  carefully  watched  and  stimulation  given  if  necessary. 
Strychnin  nitrate  has  served  us  the  best  for  this  purpose.  Where 
deglutition  is  interfered  with  gavage  may  be  necessary,  although  care- 
ful feeding  from  the  spoon  in  small  quantities  can  usually  be  success- 
fully practised.  The  food  should  be  as  nourishing  as  possible,  and 
the  appetite  and  general  health  are  improved  by  placing  the  patient 
as  much  as  possible  in  the  open  air. 

Facial  Paralysis. 
(BelVs  Palsy.) 

Paralysis  of  the  seventh  nerve  is  not  an  infrequent  affection  in 
infants  and  children.  » 

Etiology. — During  infancy  it  may  occur  as  a  result  of  pressure 
upon  the  nerve  with  the  forceps  or  in  contracted  pelves  from  impac- 
tion upon  the  head.  Caries  of  the  petrous  portion  of  the  temporal 
bone  accompanied  with  inflammatory  exudates  may  cause  paralysis 
by  pressure  on  the  nerve. 

In  children  over  three  years  of  age  sudden  exposure  to  cold, 
which  in  all  probability  induces  an  infection,  is  the  commonest  cause. 
It  may  also  accompany  or  be  produced  by  traumatism  within  the  skull, 
basilar  forms  of  meningitis,  polioencephalitis,  and  tumors  of  the  brain. 


506 


DISEASES  OF  CHILDREN. 


We  frequently  see  this  paralysis  following  the  radical  mastoid  op- 
eration in  which  the  nerve  may  be  temporarily  injured  or  destroyed, 
usually  as  a  result  of  incompetent  surgery. 

Symptomatology. — Inspection  of  the  child's  face  will  show  a 
droop  at  the  mouth  on  the  affected  side  and  the  natural  folds  in  this 
region  almost  or  quite  disappear,  while  the  angle  of  the  mouth  is 
drawn  down.  The  child  cannot  close  its  eye,  and  if  attempts  are  made 
to  do  so  the  eye-ball  moves  upward.     It  can  only  blow  out  the  cheek 

on  the  unaffected  side.  The 
protruded  tongue  deviates  to 
the  unaffected  side  and  food 
particles  may  lodge  between 
the  cheek  and  gums.  Speech 
may  be  affected,  while  attempts 
at  whistling  or  laughing  accen- 
tuate the  paralysis. 

Prognosis. — This  is  good 
for  those  cases  due  to  sudden 
chilling.  Pressure  palsies  at 
birth  may  recover  in  whole  or 
in  part.  If  due  to  destructive 
disease  in  the  petrous  portion 
of  the  temporal  bone  or  to 
intracranial  diseases,  the  prog- 
nosis is  bad.  Following  oper- 
ative procedures  the  prognosis 
depends  upon  the  amount  of 
traumatism  the  nerve  has  sus- 
tained, and  many  of  these  cases  slowly  recover  even  after  complete 
section. 

Treatment. — In  the  mild  cases  recovery  will  take  place  without 
any  treatment.  The  galvanic  current  is  used  in  the  severer  cases  and 
in  those  which  follow  operativ,e  procedures  in  conjunction  with  mas- 
sage and  mild  vibratory  treatments.  As  the  power  returns  the  child 
may  be  encouraged  to  exercise  the  muscles  by  imitating  grimaces' or 
blowing  upon  musical  instruments.  If  a  neglected  otitis  media  is 
the  cause,  surgical  procedures  are  indicated. 


Fig.  133. — Facial  Paralysis. 


CHAPTER  XXXVIII. 

DISEASES  OF  THE  SPINAL  CORD. 

Myelitis. 

Myelitis  or  inflammation  of  the  spinal  cord  may  be  divided  ac- 
cording to  the  course  into  an  acute,  a  subacute,  and  a  chronic  form. 

Etiology. — It  may  result  from  injuries  severe  or  even  considered 
mild  in  character.  It  may  follow  the  acute  infectious  fevers  and  septic 
processes  anywhere  in  the  body. 
It  may  extend  or  result  from  a 
meningitic  process.  It  may  also 
be  caused  by  new  growths  in 
the  spinal  canal.  Syphilis  and 
Pott's  disease,  however,  are  the 
two  causes  which  are  most  com- 
mon in  children. 

Pathology. — The  cord  on 
section,  in  the  affected  areas, 
shows  a  congestion  of  its  men- 
inges, while  the  cord  itself  has 
been  changed  to  a  soft  pulpy 
mass.  The  white  matter  is  with 
difficulty  distinguished  from  the 
gra}'.  Minute  capillary  hemor- 
rhages are  found  throughout  the 
gray  matter  and  the  cells  in  the 
anterior  horn  show  marked  de- 
generative changes.  The  blood- 
vessels of  the  cord  are  dilated 
with  proliferation  of  leukocytes, 
amalacious  bodies,  and  degener- 
ated axis-cylinders.  In  the  sub- 
acute or  chronic  forms  some 
evidences  of  sclerosis  may  be 
found. 


Fig.  134. — Lumbar  myelitis,  showing  con- 
tractures and  deformities. 


Symptomatology. — In  acute  myelitis  there  is  a  sudden  onset  with 
a  temperature  which  may  rise  to  104°  F.  as  a  result  of  the  infective 
process.  Painful  areas  may  be  elicited  on  pressure  along  the  spine 
or  the  tenderness  may  be  subjective.     Clinical  evidence  will  soon 

507 


508 


DISEASES  OF  CHILDREN. 


appear  of  functional  disturbance  of  the  cord  and  will  vary  with  the 
intensity  and  localization  of  the  process.  The  myelitis  will  affect 
motion  and  sensation  and  derange  the  functions  of  the  bladder  and 
rectum.  Paraplegia  results.  Anesthesia  will  be  present  in  the  parts 
of  the  body  supplied  by  the  nerves  which  originate  below  the  involved 
area.  Thus  there  is  loss  of  such  sensory  impulses  as  pain,  touch, 
thermal  and  muscular  sense.  A  hyperesthetic  zone,  due  to  the  irrita- 
tion of  the  nerve  fibers  may  be  present  above  the  anesthetic  area. 
The  reflexes  are  disturbed  depending  upon  the  area  involved. 


Fig.  135. — Bed-sores  in  myelitis. 


Cervical  lesions  cause  a  paralysis  in  all  four  extremities.  In 
the  arms  it  will  be  flaccid  in  type,  while  in  the  lower  extremities 
the  palsy  will  be  spastic  in  character.  The  whole  body  is  anesthetic 
below  the  neck.  In  the  dorsal  region  which  is  most  commonly 
affected  in  children  the  upper  extremities  are  not  involved,  while  the 
lower  become  spastic.  The  patellar  and  plantar  reflexes  are  increased 
and  ankle  clonus  is  present.  Lumbar  lesions  produce  a  flaccid  paraly- 
sis in  the  lower  extremities  which  is  later  accompanied  by  some  degree 
of  atrophy.  The  urine  dribbles  away  and  the  rectum  is  incontinent. 
The  reflexes  are  lost  and  sensation  is  absent  to  a  point  above  the  lesion. 
Bed-sores,  the  result  of  trophic  disturbances,  cystitis,  and  infections 
of  the  urinary  tract  easily  occur,  and  in  fact  may  bring  the  case  to  a 


DISEASES  OF  THE  SPINAL  CORD.  509 

fatal  issue.  Contractures  and  deformities  may  result  in  the  extremi- 
ties unless  measures  are  taken  for  their  prevention. 

Diagnosis. — The  etiological  factor,  the  sudden  onset,  the  paralysis 
of  a  flaccid  type  above  and  spastic  below,  accompanied  with  anesthesia 
and  derangements  of  the  bladder  and  rectum  should  make  the  diag- 
nosis easy. 

Prognosis. — Lesions  in  the  cervical  region  are  the  most  danger- 
ous to  life.  Myelitis  in  the  dorsal  and  lumbar  region  may  cause  death 
from  infective  processes  arising  in  the  bladder,  rectum,  or  from  bed- 
sores. The  younger  the  child,  the  more  unfavorable  the  prognosis. 
Syphilitic  cases,  if  the  diagnosis  is  made  easily,  should  give  favorable 
results  under  specific  treatment. 

Treatment. — Acute  Stage. — Absolute  rest  in  bed  on  an  air  mat- 
tress is  essential.  Ice  bladders  may  be  placed  over  the  spine  while 
the  fever  is  active  and  for  the  relief  of  pain.  The  bowels  are  emptied 
by  a  brisk  cathartic,  and  the  bladder  relieved  by  an  attendant  accus- 
tomed to  surgical  cleanliness.  In  syphilitic  cases  the  mercurials  with 
the  iodids  are  given.  If  there  is  intolerance  to  these,  the  mercury 
may  be  given  by  inunction.  If  a  specific  infectious  process  can  be  dem- 
onstrated, such  as  streptococci,  and  isolated  from  the  patient's  own 
blood,  treatment  by  vaccines  may  be  tried.  Bed-sores  must  be  guarded 
against  by  scrupulous  cleanliness,  frequent  change  of  position,  and  the 
daily  application  of  alcohol  or  astringents.  If  they  do  develop  they 
should  be  thoroughly  cleansed  and  treated  with  stimulating  antisep- 
tics, such  as  silver  nitrate. 

After  the  subsidence  of  the  acute  symptoms,  skilled  massage 
may  be  employed  in  conjunction  with  warm  tonic  baths.  Arrange- 
ments should  be  made  so  that  the  child  can  be  taken  out  of  doors  on 
a  roller  bed  or  chair  so  that  its  nutrition  may  be  preserved  and  its  de- 
sire for  food  stimulated. 


Multiple  Sclerosis. 
{Disseminated  Sclerosis.) 

The  disease  may  have  its  inception  in,  or  it  may  be  associated 
with  any  of  the  acute  infectious  diseases. 

Pathology. — Throughout  the  central  nervous  system  patches  of 
sclerosis  are  found.  They  may  be  more  frequent  in  one  area  than 
in  another,  invading  the  brain,  the  pons,  the  medulla,  the  lateral  and 
the  posterior  columns  of  the  spinal  cord,  or  even  the  spinal  roots 
may  be  affected.     Closer  examination  shows  that  the  myelin  sheaths 


510  DISEASES  OF  CHILDREN. 

of  the  nerve  fibers  are  destroyed,  although  the  axis-cylinders  in  the 
sclerotic  areas  do  not  suffer. 

Symptomatology. — At  first  there  may  be  weakness  of  the  upper 
and  lower  extremities  accompanied  with  some  trembling  of  the  hands 
and  the  development  of  a  spastic  gait.  This  is  followed  by  an  inten- 
tion tremor  which  is  quite  characteristic  of  this  disease,  and  which 
is  accentuated  by  voluntary  action  on  the  part  of  the  patient.  It 
disappears  when  the  extremity  is  at  rest.  Later  in  the  disease  the 
tremor  may  be  so  intense  as  to  prevent  the  ordinary  activities,  as 
dressing  or  eating,  etc.  A  speech  defect  now  appears;  it  is  slow,  de- 
liberate, careful,  with  a  tremulous  character.  It  is  spoken  of  as  scan- 
ning speech.  Nystagmus  or  oscillation  of  the  eye-ball  appears  at  this 
time  and  is  especially  marked  when  lateral  movements  are  attempted. 
The  pupils  usually  are  contracted  and  reaction  of  accommodation  to 
light  is  sluggish.  The  mental  faculties  become  impaired,  memory 
particularly  is  poor,  and  sudden  emotional  changes  occur  on  the  least 
provocation.  The  expression  of  the  face  becomes  dull  and  stupid. 
A  spastic  form  of  paralysis,  not  very  apparent  at  first,  later  becomes 
well-marked,  producing  a  spastic  gait.  As  the  disease  advances  the 
tremor  becomes  so  intense  that  walking  is  impossible,  and  finally 
the  patient  is  bed-ridden.  After  a  long  and  tedious  course  the  disease 
finally  ends  fatally,  the  patient  dying  of  some  intercurrent  disease. 

Treatment. — All  that  can  be  done  for  this  incurable  disease  is  to 
regulate  the  life  of  the  patient  so  that  an  unusual  amount  of  rest  is 
secured  and  the  muscles  kept  in  good  condition  by  baths,  massage, 
vibratory  treatment,  and  the  galvanic  current.  Drugs  do  not  in- 
fluence the  disease,  and  if  given  at  all  they  should  be  prescribed  for 
symptoms  as  they  arise. 

Hereditary  Ataxia. 

{Friedreich' s  Ataxia.) 

This  is  a  disease  occurring  in  the  members  of  the  same  family 
and  characterized  by  an  ataxia  with  a  slow  but  progressive  course. 

Etiology. — The  disease  is  hereditary  in  character,  passing  often 
through  several  generations.  The  males  or  the  females  of  a  family 
inherit  the  disease.  The  spinal  symptoms  in  some  cases  predominate, 
and  in  others  the  cerebellar  are  more  in  evidence.  The  spinal  form 
occurs  in  the  ages  of  four  to  seven,  while  the  cerebellar  form  is  rarely 
seen  before  the  twentieth  year. 

Pathology. — The  changes  found  are  in  the  posterior  roots.  There 
is  sclerosis  of  the  posterior  columns.     The  spinal  cord  as  a  whole  is 


DISEASES  OF  THE  SPIXAL  CORD. 


511 


smaller  than  normal.  In  some  cases  the  lateral  tracts  and  the  columns 
of  Clark  are  atrophic,  especially  in  the  type  known  as  the  cerebellar, 
in  which  there  is  a  marked  diminution  in  the  size  of  the  cerebellum 
and  degeneration  of  its  nerve  tracts. 

Symptomatology. — The  gait 
is  the  first  symptom  to  attract 
attention.  The  walk  is  swaying 
in  character  with  the  legs  held 
apart  (sailor  fashion) ,  even  while 
sitting  and  standing  the  patient 
cannot  control  his  position  ac- 
curately. Athetoid  movements 
or  tremors  are  present,  especially 
in  the  extremities.  Hyperex- 
tension  of  the  great  toe  may  be 
an  early  symptom  and  later  de- 
formities, as  pes  equinus,  may 
develop.  Romberg's  symptom 
is  obtained  in  the  spinal  cases, 
but  is  more  strongly  marked  in 
the  cerebellar  type.  The  patellar 
reflex  is  variable  and  inconstant, 
and  cannot  be  depended  upon 
for  much  diagnostic  aid.  The 
cutaneous  reflexes  also  remain 
quite  normal.  Atrophy  of  mus- 
cle after  a  time  occurs  and  pro- 
duces such  deformities  as  scoli- 
osis and  thus  destroys  the  normal 
spinal  curves.  Nystagmus  is  a 
quite  constant  symptom.  The 
pupils  are  normal,  but  other 
ocular  disturbances,  as  ptosis 
and  strabismus,  occur.  Optic 
atrophy  is  not  rarely  found  in 
the  later  stages.  Dysarthria  is 
commonly  present.  Sensation 
is  unimpaired.      The  sphincters 

do  not  suffer.     As  the  disease  progresses  signs  of  failing  intellect  are 
observed;  these  may  be  preceded  by  dizziness  or  hysterical  phenomena. 

Differential  Diagnosis.— Tabes  dorsalis  may  be  differentiated  by 
the  absence  of  lightning  pains  and  sphincteric  changes,  and  again  the 


Fig.  136. 


Hereditary  ataxia  {Friedrich's 
disease).  {Sachs.) 


512  DISEASES  OF  CHILDREN. 

ataxic  gait  is  rarely  seen  in  infantile  tabes,  while  the  pupillary  changes 
are  frequent.  New  growths  of  the  cerebellum  might  simulate  a  begin- 
ning ataxia,  but  the  course  is  more  rapid  and  there  is  headache  and 
vomiting. 

Course  and  Prognosis. — The  disease  is  extremely  slow  in  its 
progress.  Eventually,  after  years,  the  patient  is  bed-ridden  after  the 
musculature  is  invaded.  Death  occurs  from  some  intercurrent 
malady.     The  prognosis  is  invariably  bad. 

Treatment. — A  nutritious  diet,  massage,  hydrotherapy,  and  the 
best  possible  hygienic  surroundings  are  our  only  recourse.  Medicinal 
treatment  is  symptomatic  only.     Iron  is  necessary  for  the  anemia. 

Primary  Myopathy. 

{Muscular  Dystrophy;   Idiopathic  Muscular  Atrophy.) 

For  the  purposes  of  clearness  and  to  prevent  the  confusion  which 
must  arise  in  the  mind  of  the  reader  attempting  to  gain  information 
on  this  topic,  we  will  embrace  all  the  various  described  types  under 
this  one  general  title  of  the  myopathies. 

Clinically,  these  types  have  been  separated  on  a  basis  of  age,  as 
the  juvenile  (Erb  type)  and  the  infantile  type;  on  an  anatomical  basis, 
for  example,  the  facio-scapulo-humeral  type  (Landouzy-Dejernie); 
and  still  another  type  is  based  on  the  distal  involvement,  i.e.,  those  in 
which  the  proximal  parts  of  the  body  remain  intact  for  many  years 
and  only  the  distal  parts  are  affected;  finally  on  an  objective  basis, 
in  which  there  is  enlargement  or  apparent  hypertrophy  of  portions  of 
the  body  (pseudohypertrophic  muscular  paralysis  of  Duchenne). 

Pathological  classification  offers  no  relief  at  present  from  the  ap- 
parent confusion,  as  the  study  of  muscle  components  and  muscle 
embryology  has  not  as  yet  advanced  sufficiently  to  warrant  such  a 
classification. 

Etiology. — Gowers  suggests  that  the  myopathies  are  due  to  an 
inherent  defective  vital  endurance.  Collins  says  they  are  an  expres- 
sion of  prenatal  inadequate  endowment.  Maternal  heredity  seems  to 
have  a  distinct  place,  while  paternal  heredity  because  of  the  early 
impotency  of  the  diseased  father  is  to  be  disregarded.  Several 
members  of  one  family  may  be  attacked.  The  affection  usually  begins 
about  the  sixth  to  the  eleventh  years  of  life.  Although  cases  have 
been  reported  occurring  at  birth,  and  as  late  as  the  thirties.  Boys 
are  more  frequently  seen  with  the  disease  than  girls.  A  history  of 
trauma  is  often  given  as  a  cause  by  the  parents,  but  may  be  disre- 
garded in  a  disease  of  this  causation.     The  acute  exanthemata,  espe- 


DISEASES  OF  THE  SPINAL  CORD.  513 

cially  scarlet  fever,  may  so  lower  the  resistance  that  the  disease  is 
more  readily  ushered  in. 

Pathology. — Various  anatomical  changes  have  been  found,  but 
the  reports  are  various  and  confusing.  The  nervous  system  does  not 
seem  to  be  involved  insofar  as  modern  technic  can  discover  in  the 
normal  case.     Gowers  rejects  the  theory  that  the  disease  may  be  a 


Fig.  137. — Position  assumed  by  myopathic  patient  climbing  up  stairs     {Collins.) 

trophoneurosis.  The  cells  in  the  dorsal  ganglia  have  been  found 
shrunken  by  Brooks  and  others.  The  muscles  themselves  show  the 
true  pathological  changes.  Atrophy  and  hypertrophy  of  muscle 
fibers  may  be  seen  in  the  same  specimen.  Fatty  deposits  and  connec- 
tive-tissue increase  are  likewise  found.  In  some  cases  (the  pseudo- 
hypertrophic type)  the  adipose  tissue  is  in  excess,  while  in  others  (the 
so-called  sclerotic  type)  the  connective-tissue  elements  predominate. 
In  the  latter  form  the  muscles  become  firm  and  thin  and  later  simply 
33 


514  DISEASES  OF  CHILDREN. 

degenerate  into  fibrous  bands.     The  lipomatous  type  is  never  hard, 
but  soft  and  flabby. 

Symptomatology. — The  first  symptom  noticed  may  be  a  weakness 
in  walking  or  clumsiness  in  going  up  or  down  stairs;  later  the  child 
stumbles  or  falls  on  slight  provocation.  These  symptoms  come  on 
very  gradually,'  so  that  they  are  often  considered   negligible   in  the 


Fig.  138.— Position  taken  by  the  myopathic  when  rising  from  the  floor.   (Collins.) 

dispensary  patients,  especially  as  they  seem  to  be  physically  in  very 
good  condition.  The  calves  may  seem  to  the  laity  to  be  unusually 
well  developed.  When  the  disease  is  more  advanced  the  gait  be- 
comes waddling,  the  legs  are  not  lifted  much  from  the  ground.  If  a 
test  is  now  made  a  very  characteristic  attitude  will  be  assumed,  namely 
that  of  "climbing  up  on  himself;"  especially  if  the  patient  attempts 
to  pick  an  object  from  the  floor.  If  placed  on  his  back  on  the  floor, 
the  patient  is  obliged  slowly  to  turn  face  downward,  get  on  his  knees 


DISEASES  OF  THE  SPINAL  CORD.  515 

with  the  aid  of  his  arms,  then  raising  his  knees  he  forms  an  arch  and 
now  by  grasping  his  knees  he  works  his  hands  higher  and  higher  up 
the  thighs  until  he  can  assume  the  erect  posture.  In  advanced  cases 
even  this  is  impossible  and  the  child  is  finally  bed-ridden.  The 
knee  and  ankle  reflex  are  diminished,  and  in  terminal  stages  entirely 
absent. 


Fig.  139. — Myopathic  boy  in  early  stages,  Fig.    140. — Myopathy    (hyper- 

yhowing    winged     scapulae    and    lordosis.        trophic)     four     years     duration. 
(Collins.)  {Collins.) 


The  posture  is  also  quite  characteristic.  Lordosis  is  sometimes 
seen  quite  early,  and  at  this  time  it  disappears  if  the  child  is  asked  to 
sit  down.  As  the  disease  advances,  the  lordosis  is  more  marked,  the 
head  and  pelvis  is  held  well  back  and  no  change  is  observed  in  the 
sitting  position.  The  face  loses  its  original  expression,  becoming 
dull  and  mask-like.     When  the  disease  is  well  advanced  even  closure 


516  DISEASES  OF  CHILDREN. 

of  the  eye-lids  is  accomplished  with  difficulty  and  articulation  is  im- 
perfect. All  these  changes  are  due  to  atrophy  of  the  facial  muscles 
in  some  degree.  The  lower  extremities,  while  mainly  involved,  are  not 
alone  affected.  After  several  years  the  shoulder  group  muscles  begin 
to  lose  their  power,  the  patient  is  unable  to  raise  his  arms  and  flex  his  el- 
bows, but  they  still  are  able  to  perform  the  finer  movements  of  the 
hand.  The  supraspinatus  muscle  Gowers  describes  as  being  almost 
the  last  to  become  affected.  The  atrophic  muscles  allow  the  shoulder 
blades  to  recede  from  the  thorax,  forming  the  winged  scapulae  so  often 
observed  in  the  myopathies. 

Electrical  Examination. — Reaction  of  degeneration  is  not  obtained. 
There  is,  however,  lessened  excitability  to  both  currents. 

Complications. — Fractures,  contractures,  and  deformities  may  oc- 
cur in  these  cases.  The  fractures  are  due  to  the  stumbling  or  awk- 
wardness of  the  patient.  Various  theories  have  been  advanced  by 
neurologists  for  the  contractures,  but  suffice  it  to  say,  that  they  are  of 
all  possible  varieties  that  are  reducible  and  subject  to  relapse. 

Collins  and  Climenko  give  the  following  order  in  which  the  mus- 
cles are  involved: 

Dense,  Thickened  Muscles. — calves,  sartorius,  glutei,  triceps,  del- 
toids, infraspinati. 

Atrophy. — ^Pectoralis  major,  trapezius,  serratus  magnus  (anterior 
portion),  latissimus  dorsi,  biceps,  quadriceps  femoris,  abductors. 

Differential  Diagnosis.  —  The  characteristic  features  are  the 
disproportionately  enlarged  calves,  the  peculiar  facies,  the  gait,  the 
lordosis  and  the  peculiar  attitude  assumed  when  arising  from  the 
prone  position.  Atypical  cases  are  often  puzzling  and  must  be  differ- 
entiated from  anterior  poliomyelitis  in  which  there  is  a  regular  corre- 
sponding distribution  of  the  affected  muscles  to  the  portion  of  cord 
involved,  while  in  dystrophy  this  is  not  so.  In  chronic  progressive 
anterior  poliomyelitis,  there  is,  besides  the  regular  muscle  grouping, 
the  reaction  of  degeneration  and  the  absence  of  pseudohypertrophy. 
In  syringomyelia  the  early  involvement  of  the  finger  muscles  serves 
as  a  guide,  for  in  the  dystrophies  these  often  remain  unaffected  to  the 
last.  Progressive  muscular  atrophy  may  be  confusing,  but  the  age, 
the  origin  in  the  digital  muscles  and  the  fibrillary  twitchings  which 
are  present  will  distinguish  the  disease. 

Treatment. — These  cases,  unfortunately,  are  not  amenable  to  cure. 
Much  can  be  done,  however,  by  obtaining  complete  control  of  the  pa- 
tient's daily  life.  Directions  should  be  given  to  supply  a  liberal  nutri- 
tious diet.  Exercises  should  be  carefully  carried  out,  especially 
valuable  being  those  of  the  resistant  form,  the  physician  or  a  trained 


DISEASES  OF  THE  SPINAL  CORD.  517 

assistant  should  by  example  teach  the  child  the  various  movements. 
Electricity  will  assist  the  gymnastic  movements  if  the  faradic  current 
is  used.  Massage  will  keep  up  to  some  extent  the  muscle  nutrition, 
The  orthopedist  must  be  consulted  and  deformities  corrected  in  their 
incipiency. 


CHAPTER   XXXIX. 
DISEASES  OF  THE  BRAIN. 

Meningitis. 

Pachymeningitis,  an  inflammation  involving  the  dura  mater,  is 
rare  in  early  life.  It  may  occur  in  connection  with  injuries  of  the  skull 
or  ear  disease,  and,  in  acute  cases,  usually  affects  only  the  external 
portion  of  the  dura.  A  more  chronic  form  is  seen  in  connection  with 
hemorrhages  on  the  vertex,  when  the  pia  as  well  as  the  internal  surface 
of  the  dura  are  involved  in  the  inflammation.  Such  hemorrhages  are 
liable  to  occur  in  feeble  infants  suffering  from  some  exhausting 
disease.  This  low  grade  of  meningitis  is  more  apt  to  be  discovered 
at  autopsy  than  during  life. 

Acute  leptomeningitis,  or  inflammation  of  the  pia,  has  already 
been  described  in  its  two  most  common  forms  —  acute-  cerebro- 
spinal meningitis  and  tuberculous  meningitis.  There  is,  in  addition, 
a  form  that  may  be  different  in  its  causative  factors  from  these  two 
varieties,  although  there  is  a  certain  similarity  in  symptoms. 

Etiology. — Instead  of  the  diplococcus  intracellularis  or  tubercle 
bacillus  acting  as  a  cause,  we  may  have  a  number  of  microbes,  seen  in 
connection  with  injuries  of  the  skull,  ear  disease,  or  various  infectious 
diseases,  producing  inflammation  of  the  pia.  In  these  cases  it  is 
more  distinctly  a  secondary  disease.  Any  traumatism  of  the  skull 
from  falls  or  blows,  suppuration  after  cranial  operations,  disease  of  the 
middle  or  internal  ear  or  mastoids,  can  afford  access  to  the  various 
forms  of  streptococci  or  staphylococci  that  may  attack  the  pia.  It 
may  also  be  affected  by  the  pneumococcus,  the  typhoid  bacillus,  the 
influenza  bacillus  and  rarely  by  the  Klebs-Loeffler  bacillus  and  the 
gonococcus.  A  meningitis  may  thus  be  seen  in  connection  with  pneu- 
monia, typhoid  fever,  influenza,  scarlet  fever,  diphtheria,  and  as  a 
terminal  infection  in  almost  any  chronic  infectious  disease. 

Symptomatology. — The  symptoms  of  all  varieties  of  meningitis 
are  generally  alike,  although  differing  somewhat  in  the  course,  rapidity 
and  sequence  of  the  various  manifestations.  As  a  secondary  condition 
the  symptoms  are  apt  to  be  masked  at  first  by  the  course  of  the  original 
disease.  The  occurrence  of  projectile  vomiting,  convulsions,  irregular 
respiration  and  pulse,  stupor,  or  coma  will  call  for  a  diagnosis  of  men- 

518 


DISEASES  OF  THE  BRAIN.  519 

ingitis  during  the  original  infection.  The  symptoms  will  vary  according 
to  the  part  of  the  brain  involved.  Where  the  inflammation  involves 
principally  the  convexity,  as  may  be  seen  in  pneumonia  or  malignant 
endocarditis,  there  may  be  no  symptoms  besides  the  stupor  to  dis- 
tinguish it  from  the  original  infection.  Where  the  inflammation  is  at 
the  base  of  the  brain,  the  cranial  nerves  are  apt  to  become  involved  and 
there  will  be  various  paralyses  and  some  retraction  of  the  head.  Where 
the  inflammation  extends  from  the  middle  ear  or  mastoid,  meningitis 
at  the  beginning  will  be  unilateral  and  may  continue  so  during  the 
course  of  the  disease,  and  facial  paralysis  may  ensue  on  the  affected  side 
in  addition  to  the  other  symptoms.  The  meninges  over  the  first  and 
second  temporal  convolutions  are  apt  to  be  especially  involved  in  the 
ear  cases.  In  all  varieties,  when  the  meningitis  is  well  under  way  there 
will  be  hyperesthesia  of  the  skin,  and  there  may  be  local  or  general 
convulsions,  photophobia,  stupor  or  coma,  and  irregularities  of  the 
pulse  and  respiration.  The  temperature  is  irregular  and  is  influenced 
b}'  the  primary  disease.  The  duration  of  secondary  meningitis  is 
usually  short,  from  a  few  days  to  a  w^eek,  and  the  prognosis  is  bad. 
We  have,  however,  seen  a  few  cases  recover  where  the  original  dis- 
ease was  controlled  and  the  meningitis  apparently  not  extensive. 

Diagnosis. — Lumbar  puncture  will  aid  in  differentiating  the 
various  forms  of  meningitis  by  a  discovery  of  the  causative  microbe 
in  the  fluid  withdrawn.  On  the  clinical  side,  the  secondary  nature  of 
the  meningitis  will  be  shown  by  its  onset  during  the  course  of  some 
general  infectious  disease  or  when  there  is  a  recognized  lesion  in  the 
ear  that  is  probably  being  treated.  Acute  cerebrospinal  meningitis 
is  sudden  in  its  onset,  without  any  previous  disease,  and  as  the  lesion 
is  apt  to  involve  all  the  surface  of  the  brain  as  well  as  the  cord,  the 
symptoms  are  general  and  severe  from  the  first.  Tuberculous  meningi- 
tis is  very  slow  and  irregular  in  its  onset,  sometimes  taking  as  long  as 
several  weeks  to  attain  its  maximum  intensity,  and  the  brunt  of  the 
lesion  is  usually  at  the  base  of  the  brain. 

Treatment. — The  principal  effort  must  be  directed  toward  a  free 
drainage  of  any  localized  suppuration  in  the  ear  or  skull  that  may  be 
causing  the  infection.  We  have  seen  cases  of  sinus  thrombosis  induc- 
ing meningitis,  both  relieved  by  surgical  measures.  The  general  man- 
agement is  the  same  as  in  other  forms  of  meningitis.  The  bowels 
must  be  freely  openetl  and  bromids  given  to  relieve  pain.  An  ice-bag 
may  be  intermittently  applied  to  the  head,  and,  if  there  is  much  evi- 
dence of  intracranial  pressure,  lumbar  puncture  may  be  employed. 
Small  doses  of  iodid  of  potash  may  also  be  tried.  The  nourishment 
must  consist  of  milk,  meat  broths,  or  similar  easily  assimilable  foods. 


520  DISEASES  OF  CHILDREN. 

Acute  Encephalitis. 

This  is  an  inflammation  of  the  brain  tissue  usually  occurring  in 
connection  with  meningitis  from  an  extension  inward  of  the  inflam- 
matory process.  The  symptoms  are  largely  the  same  as  those  caused 
by  inflammation  of  the  pia.  They  will  var}',  however,  as  to  whether 
the  convexity  or  base  of  the  brain  is  the  principal  seat  of  the  disease. 
In  the  former  case  there  will  be  convulsions,  paralyses,  and  coma,  and 
in  the  latter,  cranial  nerve  paralyses  will  form  the  dominant  symptoms. 
Strumpell  describes  a  hemorrhagic  encephalitis  occurring  in  connection 
with  influenza  or  other  infectious  disease.  It  may  then  be  seen  without 
a  coexisting  meningitis.  There  is  severe  pain  in  the  head  followed  by 
stupor  and  eventually  b}^  coma.  In  other  cases  there  will  be  great  rest- 
lessness, alternating  with  drowsiness.  There  is  apt  to  be  rigidity 
of  the  neck;  in  some  cases  there  may  be  loss  of  power  in  an  arm  or  leg, 
and  in  others  hemiplegia  may  ensue.  Fever  is  present  and  the  pulse 
and  respiration  are  irregular.  In  mild  cases,  recovery  may  occur  after 
one  or  two  remissions,  but,  in  the  severer  types  death  usually  takes 
place  in  coma  after  an  interval  of  from  one  to  three  weeks.  The  treat- 
ment is  the  same  as  in  meningitis. 

Abscess  of  the  Brain. 

Cerebral  abscess,  single  or  multiple,  may  occur  in  early  life. 
The  white  matter  is  more  apt  to  undergo  suppuration  than  the  gray 
matter,  and  hence  abscesses  form  more  frequently  within  than  on  the 
surface  of  the  brain.  The  temporosphenoidal  lobes,  the  frontal  lobes, 
and  the  cerebellum  are  most  frequently  attacked. 

Etiology. — Boys  are  more  often  affected  than  girls,  and  the  most 
frequent  cause  is  ear  disease,  especially  if  there  is  a  secondary  involve- 
ment of  the  petrous  portion  of  the  temporal  bone,  when  the  abscess 
is  usually  located  in  the  temporosphenoidal  lobes  or  occasionally  in 
the  cerebellum.  Injuries  of  the  skull  due  to  trauma  and  sinus 
thrombosis  occurring  in  connection  with  such  injuries  or  with  ear 
disease  may  cause  abscess.  Infective  processes  within  the  nose 
may  spread  to  the  brain  and  induce  an  abscess,  and  rarely  septic  em- 
boli from  pus  formations  in  distant  parts  of  the  body  may  be  carried 
to  the  brain  and  produce  a  similar  effect. 

Symptomatology. — As  the  abscesses  do  not  commonly  form  in  the 
motor  area  of  the  brain,  the  objective  symptoms  are  often  very  ob- 
scure. If,  however,  the  abscess  does  form  or  spread  into  a  motor 
area  we  will  have  localized  symptoms,  the  same  as  seen  in  the  pressure 
effects  from  tumors  or  hemorrhage.     The  early  symptoms  are  much 


DISEASES  OF  THE  BRAIN.  521 

the  same  as  those  of  meningitis.  There  is  vomiting,  pain  in  the  head, 
fever,  and  occasionally  localized  or  unilateral  convulsions.  The  fever 
is  irregular  in  type  and  may  be  accompanied  by  chills.  If  these  symp- 
toms ensue  in  connection  with  acute  or  chronic  disease  of  the  ear, 
traumatism  of  the  cranial  bones,  or  more  distant  foci  of  suppuration 
that  may  give  off  septic  emboli,  we  may  suspect  cerebral  abscess.  In 
ease  the  abscess  becomes  encapsulated,  there  may  be  no  symptoms  at 
all,  in  this  respect  differing  from  the  disturbing  effects  of  solid  tumors. 
Optic  neuritis  is  occasionally  present.  Where  the  abscess  is  located 
at  the  base  of  the  brain,  the  different  cranial  nerves  may  become  af- 
fected. If  the  speech  centers  are  involved  in  the  abscess,  aphasia  may 
be  noted.  In  some  cases  the  pus  may  rupture  into  the  ventricles, 
thereby  producing  serious  and  urgent  symptoms. 

Diagnosis. — It  is  often  impossible  to  differentiate  abscess  from 
meningitis,  encephalitis,  or  tumors  of  the  brain.  If,  in  connection 
with  the  symptoms  of  brain  disturbance  seen  in  common  with  the 
latter  conditions,  there  is  a  high,  irregular  fever  with  chills,  and  if 
ear  disease  or  trauma  of  the  skull  exists,  we  may  strongly  suspect  the 
formation  of  an  abscess.  A  differential  blood  count  and  lumbar 
puncture  may  aid  in  establishing  the  diagnosis. 

Prognosis. — The  prognosis  is  bad,  but  if  the  abscess  can  be  located 
and  treated  surgically,  recovery  occasionally  takes  place. 

Treatment. — Any  suppurating  area  involving  the  ear  or  bones  of 
the  skull  must  be  carefully  watched  and  thorough  drainage  maintained. 
If  the  symptoms  point  to  internal  abscess  the  surgeon  must  trephine 
and  endeavor  to  open  and  drain  the  abscess.  The  first  and  second 
temporal  convolutions  are  most  often  the  seat  of  abscess  following 
ear  disease.  The  deeper-seated  abscesses  may  be  located  by  inserting 
a  needle  into  the  part  of  the  brain  suspected. 

Brain  Tumors. 

Tuberculous  tumors  predominate,  consisting  usually  of  a  caseous 
tumor  of  the  cerebellum.  Gliomata,  sarcomata,  and  cysts  occur  usu- 
ally in  the  cerebellum  and  pons.  Males  are  more  prone  than  females. 
Infants  under  six  months  very  rarely  have  brain  tumors.  Tubercu- 
lous and  sarcomatous  growths  are  secondary  to  growtljs  elsewhere  in 
the  body. 

Symptomatology. — These  are  produced  by  pressure,  irritation, 
exudation,  or  interference  with  the  blood  supply  and  vary  also  with 
the  location  involved. 

Headache. — This  is  persistent  and  boring  in  character,  causing 


522  DISEASES  OF  CHILDREN. 

restlessness,  insomnia,  rolling  of  the  head,  cephalic  cry,  and  photopho- 
bia.    Occasionally  the  pain  is  well  localized  at  the  site  of  the  tumor. 

Nausea  and  Vomiting. — This  is  persistent  and  without  causal  re- 
lation to  food.     It  is  projectile  in  character. 

Vertigo  or  dizziness  are  common  symptoms,  elicited  by  change  of 
position.     The  gait  may  be  reeling. 

Ocular  symptoms  are  particularly  helpful — optic  neuritis  in  one 
or  both  eyes  is  usually  present,  and  especially  so  when  the  cerebellum 
is  affected.  Optic  atrophy  may  follow  and  is  seen  early  if  the  chiasm 
is  involved. 

Convulsions  occur  when  the  cortex  and  motor  areas  are  involved. 
They  are  general  or  local  in  character.  Tumors  which  have  not 
as  yet  invaded  the  cortex  produce  paralysis  and  later  convulsions. 

Localization. — Special  symptoms  will  be  caused  by  involvement 
of  areas  with  known  functions,  and  are  not  different  from  those  mani- 
fested in  adults.     They  will  not  be  enumerated  here. 

Diagnosis. — From  abscess  of  the  brain,  tumors  may  sometimes 
be  distinguished  by  the  absence  of  local  causes,  lack  of  temperature, 
and  the  slower  course.  Septic  symptoms,  if  present,  are  indicative  of 
abscess,  and  are  confirmed  by  blood  examination.  MacEwen's  sign 
may  be  of  help  if  other  confirmatory  signs  are  obtained. 

Tuberculous  tumors  occur  generally  in  the  cerebellum,  and  there 
may  be  evidences  of  tuberculous  infection  elsewhere  in  the  body. 
Lumbar  puncture  should  always  be  performed  if  any  doubt  remains. 

Treatment. — Operative  procedures  are  carried  out  with  great 
risk  in  early  life  even  when  the  conditions  for  removal  of  the  growth 
are  favorable,  but  often  this  is  the  only  hope  for  relief  or  cure.  Medi- 
cal treatment  should  be  directed  to  the  relief  of  urgent  symptoms  and 
in  the  syphilitic  cases  specific  medication  should  not  be  delayed. 

Infantile  Cerebral  Palsies. 

(Spastic  Diplegia;  Paraplegia  or  Hemiplegia.) 

There  may  be  a  paralysis  of  various  parts  of  the  body  due  to 
congenital  defects,  birth  injuries,  or  hemorrhages  in  the  brain  in  later 
infancy  or  early  childhood. 

Etiology  and  Pathology. — We  may  divide  the  causes  into  those 
operating  before  birth,  during  birth,  and  some  time  after  birth.  During 
intrauterine  life  the  growth  of  the  brain  may  be  arrested  by  hemorrhage, 
by  lack  of  cortical  development,  or  by  cysts.  A  condition  known  as 
porencephaly  may  sometimes  be  present.  The  exact  cause  of  these 
accidents  or  defects  is  difficult  to  ascertain  or  explain.     They  have 


DISEASES  OF  THE  BRAIN.  523 

been  referred  to  accidents  during  pregnancy,  such  as  falls  or  blows 
on  the  abdomen,  to  uremic  convulsions,  to  severe  illness  in  such  forms 
as  pneumonia  and  typhoid  fever,  and  to  sudden  shocks  in  women 
with  a  neurotic  hereditary  tendency.  The  causes  operating  during 
birth  are  due  to  prolonged  pressure  on  the  fetal  head  in  tedious  labors 
or  to  the  unskillful  use  of  the  forceps,  as  already  noted  in  the  chapter 
on  Birth  Injuries.  The  hemorrhage  is  nearly  always  on  the  cortex, 
and  may  be  followed  by  meningoencephalitis,  sclerosis,  the  formation 
of  cysts,  or  by  atrophy  of  the  underlying  tissue.  In  later  months  or 
years,  cerebral  palsy  may  follow  a  severe  convulsion  or  a  prolonged 
paroxysm  of  whooping-cough,  and  occasionally  certain  infectious 
diseases,  such  as  scarlet  fever,  small-pox,  measles,  and  typhoid  fever, 
may  be  responsible  for  the  condition.  Direct  injury  to  the  skull 
may  also  act  as  a  cause.  The  rupture  of  cerebral  vessels  usually 
takes  place  on  or  near  the  cortex  instead  of  in  the  lenticular  nucleus 
as  in  adults.  This  has  been  explained  by  the  delicate,  fragile  structure 
of  the  small  blood-vessels  on  the  surface  of  the  brain.  Thrombosis 
and  embolism  may  act  as  a  cause  of  cerebral  palsy  in  children,  but  not 
so  frequently  as  in  later  years.  Rheumatism,  valvular  disease,  or 
pneumonia  favor  embolism,  while  any  exhausting  condition  may 
lead  to  thrombosis. 

Various  changes  occasionally  take  place  in  the  brain  following 
a  hemorrhage.  Chronic  meningitis,  sclerosis,  softening,  or  atrophy, 
with  various  degrees  of  secondary  degeneration  and  cysts,  may  be 
mentioned  in  this  connection.  The  following  tabular  classification  of 
infantile  palsies  is  taken  from  Sachs  and  gives  an  admirable  com- 
pendium of  the  subject: 

Groups.  Morbid  Lesions. 

f  Large  cerebral  defects  (porencephaly). 
,    „      ,  f  •  X       X     •  ^      \  Defective  development  of  pyramidal  tracts. 

1.  Paralyses  of  mtrauterme  onset..  j^g^j^ggig^^j.jj^^,jg     (higfiest     nerve     ele- 

(      ments  involved). 

f  Meningeal  hemorrhage,  rarely  intracerebral 

2.  Birth  palsies  ]  hemorrhage.  Later  conditions:  Meningo- 
encephalitis chronica,  sclerosis,  and  cysts; 
partial  atrophies. 

Hemorrhage  (meningeal,  and  rarely  intra- 
cerebral); thrombosis  (from  syphilitic 
endarteritis  and  in  marantic  conditions); 
embolism.  Later  conditions:  Atrophy, 
cysts,  and  sclerosis  (diffuse  and  lobar). 

Meningitis  chronica. 

Hydrocephalus  (seldom  the  sole  cause). 

Primary  encephalitis;  polioencephalitis 
acute  (Striimpell). 


3.  Acute  palsies  (acquired) . 


524 


DISEASES  OF  CHILDREN. 


Symptomatology.— The  form  and  character  of  the  paralysis 
depend  on  the  extent  and  situation  of  the  lesion.  A  double  brain 
lesion  is  apt  to  occur  early,  either  before  or  during  birth.  Diplegia 
or  paraplegia  may  thus  result.  Hemiplegia  is  occasionally  seen, 
although  not  so  often,  in  this  early  paralysis,  and  monoplegia  is  rarely, 
if  ever,  encountered  at  this  time.     The  loss  of  power  is  not  apt  to  be 

complete,  and  the  affected  muscles 
are  usually  in  a  spastic  condition. 
Very  rarely  the  muscles  may  be 
flaccid.  Contractures  early  take 
place  and  give  rise  to  various  de- 
formities. The  groups  of  muscles 
most  markedly  affected  by  these 
contractures  are  the  flexors  of  the 
legs  and  feet  and  the  flexors  and 
pronators  of  the  arms.  There  is 
usually  a  marked  exaggeration  of 
the  tendon  reflexes.  Later  on  there 
may  be  athetoid  and  occasionally 
choreiform  movements  in  the  palsied 
muscles.  Sooner  or  later  other  evi- 
dences of  cerebral  defect,  besides  the 
paralysis,  are  apt  to  manifest  them- 
selves. Epilepsy  is  perhaps  the 
most  common  of  these  disturbances. 
Many  cases  of  epilepsy  that  are  seen 
in  later  life  have  had  their  origin  in 
some  hemorrhage  or  defect  that 
originally  produced  a  palsy  in  which 
recovery  may  have  largely  taken 
place.  Another  unfortunate  sequel 
in  these  cases  is  idiocy  of  a  mild  or 
severe  grade.  The  latter  type  is  more  apt  to  follow  the  widespread 
palsies  produced  by  double  brain  lesions,  and  shown  by  diplegia  or 
paraplegia. 

In  cerebral  palsy  occurring  after  birth,  the  onset  is  usually  sudden 
and  the  form  hemiplegic.  It  is  rare  to  have  both  sides  of  the  brain 
involved,  as  so  often  occurs  before  or  during  birth.  In  hemorrhage 
on  the  cortex,  there  is  excitation  as  well  as  loss  of  function,  and  hence 
convulsions  are  usually  present  at  the  beginning.  In  later  life,  when 
the  hemorrhage  is  usually  in  the  lenticular  nucleus,  there  is  loss  of 
function,  but  little  or  no  excitation.     Aphasia  will  be  noted  in  older 


Fig.  141. — Spastic  paraplegia: 
crossed-leg  progression. 


DISEASES  OF  THE  BRAIN. 


525 


children  if  the  speech  centers  are  involved.  The  paralysis  is  usually 
not  complete  and  may  be  followed  by  contractures  and  athetoid 
movements.  While  there  is  not  the  marked  and  rapid  atrophy  seen 
in  spinal  affections,  there  is  usually  a  failure  of  proper  development 
in  the  palsied  muscles.  There  is  likewise  no  reaction  of  regeneration 
as  in  spinal  paralysis.  Considerable  recovery  of  function  often  takes 
place,  and  in  some  cases  the  prin- 
cipal disturbance  will  finally  be 
shown  by  athetoid  or  choreic 
movements  rather  than  by  paraly- 
sis. Fortunately,  mental  impair- 
ment and  epilepsy  do  not  so  fre- 
quently follow  as  in  the  birth 
palsies.  We  may  say,  in  general, 
that  these  acute  cerebral  palsies 
occur  only  in  early  childhood, 
usually  under  five  years. 

Diagnosis. — We  may  try  and 
distinguish  the  prenatal  and  birth 
palsies  from  those  occurring  later 
by  the  history  of  the  case  and  the 
extent  of  the  paralysis,  the  diple- 
gias and  paraplegias  being  nearly 
always  of  the  early  class.  The 
cerebral  is  distinguished  from 
spinal  palsy  by  its  incomplete  form, 
the  absence  of  rapid  atrophy,  by 
the  spastic  muscles,  contractures 
or  athetosis,  exaggerated  reflexes, 
and  normal  electrical  reactions. 

Treatment. 
efforts  must  be  directed  toward 
prevention.  The  expectant  mother  must  lead  a  quiet,  health}-  life 
during  pregnancy,  avoiding  undue  excitement  and  exposures  that 
may  lead  to  accident.  The  labor  must  not  be  unduly  prolonged  nor 
the  fetal  head  allowed  to  undergo  pressure  for  too  great  a  time  in  the 
maternal  passages.  The  forceps  may  be  required  to  prevent  this, 
but  they  must  be  applied  with  care,  as  extreme  pressure  from  this 
source  may  likewise  provoke  a  hemorrhage.  After  labor,  if  there  is 
any  evidence  of  cerebral  injury,  extra  care  must  be  taken  to  keep  the 
infant  very  quiet.  If  it  cannot  suckle,  the  mother's  milk  may  be 
carefully  given  by  a  medicine  dropper.     Where  there  are  twitchings  or 


-The    greatest  ^'"-  i42.— Hydrocephalus,  with  spastic 
paraplegia,  mentality  normal. 


526  DISEASES  OF  CHILDREN. 

convulsions,  small  doses  of  bromid  of  sodium  (2  to  3  grains)  may  be 
given  every  few  hours.  In  the  later  cases  of  cerebral  apoplexy,  cold 
may  be  applied  to  the  head,  and  a  free  movement  of  the  bowels  induced. 
Small  doses  of  the  bromid  of  sodium  may  likewise  be  given,  and  later 
on  this  may  be  combined  with  the  iodid  of  potash.  Massage  and 
electricity  may  be  used  in  trying  to  overcome  contractures,  but  in  old 
cases  orthopedic  appliances  are  usually  required  to  overcome  the 
various  deformities.  The  services  of  the  surgeon  in  cutting  tendons 
and  thus  relieving  tension  and  deformity  are  likewise  often  required. 

Hydrocephalus. 

Hydrocephalus  is  an  enlargement  of  the  skull  due  to  fluid  within 
the  ventricles  or  in  the  subdural  spaces. 

Several  classifications  have  been  made  of  this  condition.  We 
are  inclined  to  accept  the  etiological  as  offering  the  greatest  help  to  the 
student. 

1.  congenital  hydrocephalus    {  {.".trill-r/el^rbdS'"- 

f  Acute — inflammatory  diseases  of  the  men- 
I  inges. 

2.  Acquired  hydrocephalus -I  Chronic — result    of    inflammation    of     the 

I  external  or  internal    coverings  of 

[  the  brain. 

Congenital  External  Hydrocephalus. — Very  few  cases  of  congenital 
external  hydrocephalus  have- been  reported.  The  condition  seems  to 
result  from  an  intrauterine  meningitis  or  from  congenital  maldevelop- 
ment  of  the  brain. 

Congenital  Internal  Hydrocephalus. — As  a  result  of  intrauterine 
disease,  there  is  an  abnormal  exudation  of  fluid  which  either,  appear- 
ing early,  arrests  the  development  of  the  brain,  or,  appearing  later, 
causes  its  atrophy. 

Etiology. — Parental  alcoholism,  tuberculosis,  syphilis,  and  neurotic 
diseases  have  a  distinct  influence  in  its  causation. 

Symptomatology. — The  fluid  within  the  cranium  which  may  be 
as  much  as  5,000  c.c.  does  not  allow  normal  ossification  to  take  place; 
hence  the  tremendous  enlargement  of  the  vault;  the  sutures  are  widely 
separated,  and  the  enormously  large  fontanels  may  bulge.  The, 
bones  themselves  are  thin  plates  covered  with  a  tense  skin,  and  the 
superficial  veins  are  prominent.  The  overhanging  forehead  and  the 
pressure  within  causes  dislocation  of  the  eyes,  so  that  only  small  por- 
tions of  the  pupils  are  seen;  the  face  appears  abnormally  small  and  is 


DISEASES  OF  THE  BRAIN. 


527 


usually  emaciated.  The  expression  is  dull  and  staring,  strabismus, 
nystagmus,  lack  of  accommodation  of  the  pupils  and  even  atrophy  of 
the  optic  nerve  may  be  present.  The  child  is  pale,  wasted,  has  a  pur- 
poseless cry,  and  does  not,  as  a  rule,  thrive  even  on  a  well-regulated  diet. 
The  extremities  may  be  held  in  a  characteristic  position,  that  is, 
the  arms  are  flexed  and  the  hands  clinched.  The  infants  do  not  show 
any  interest  in  their  surroundings,  may  not  recognize  their  parents,  nor 
care  for  toys.  Convulsions  may  occur  from  time  to  time.  In  older 
children  pressure  over  the  motor  areas  due  to  the  fluid  produces 


Fig.  143. — Congenital  internal  hydrocephalus. 


spasticity,  rigidity  or  paralysis.  Walking  is  delayed  because  of  im- 
proper musculature,  lack  of  intelligence  and  a  tendency  to  the  spastic 
gait.  The  patellar  reflexes  are  increased.  Children  who  have  a  con- 
siderable amount  of  fluid  are  unable  to  support  the  head,  on  account 
of  muscular  weakness  and  the  weight.  A  peculiar  so-called  hydroceph- 
alic cry  is  occasionally  heard  in  these  cases.  In  some  cases  the  en- 
largement of  the  head  may  increase  gradually  or  suddenly  with  cere- 
bral symptoms  after  a  period  of  quiescence. 

Diagnosis.— In  well-marked  cases  it  is  simple.  The  relation  of 
the  circumference  of  the  head  to  the  chest  and  the  delayed  men- 
tality should  arouse  suspicion.  The  fluid  contains  a  trace  of  albumin 
and  sugar.  The  large  head  in  rickets  is  square,  and  other  evidences  of 
the  disease  are  found  in  the  osseous  system. 


528 


DISK\SES  OF  CHILDREN. 


Prognosis. — This  is  directly  dependent  upon  the  amount  and 
increase  of  cranial  enlargement  as  indicated  by  measurements.  As 
a  rule,  these  children,  especially  the  congenital  types,  succumb  to  inter- 
current diseases,  dying  soon  after  birth  or  in  early  childhood.  Those 
cases  in  which  the  intellect  is  not  greatly  altered  may  be  fairh'  bright, 
but  their  deformity  and  peculiar  gait  necessitates  special  school 
facilities.  A  certain  number  live  to  be  bright  and  useful  members 
of  society. 

Treatment. — Medicinal  treat- 
ment is  of  little  avail.  Those  with 
a  syphilitic  history  should  be  given 
the  benefit  of  the  mercury  and 
iodids.  Surgical  treatment  of  all 
sorts  has  been  advised  and  soon 
abandoned,  because  of  the  poor 
results  obtained.  Pressure  ban- 
dages, puncture  of  the  ventricle, 
injections  and  insufflations  into 
the  ventricles,  permanent  drainage 
from  the  ventricles  into  the  sub- 
dural space  are  among  the  various 
means  which  have  been  tried  at 
the  Post-Graduate  Hospital,  and 
each  has  been  disappointing. 
Lumbar  puncture,  or  aspiration 
of  the  ventricles  for  the  relief  of 
pressure  symptoms,  is  the  only 
procedure  which  temporarily  gives 
good  results. 


Fig.  144. — Acquired  hydrocephalus. 


Microcephalus. 

By  microcephalus  we  understand  that  condition  in  which  there 
is  arrested  or  defective  development  of  the  brain  with  a  correspond- 
ingly small  cranial  cavity. 

Microcephalus  probably  originates  during  fetal  life  or  soon  after 
birth.  The  fontanels  are  closed  and  premature  ossification  of  all 
the  sutures  takes  place.  The  vertex  is,  as  a  rule,  dome-shaped,  al- 
though it  may  be  asymmetrical  with  a  sharply  receding  forehead. 
When  the  conditon  begins  later  in  infancy,  it  is  considered  to  be  the 
result  of  minute  hemorrhages  into  the  cortex  arising  from  a  meningeal 
disease  or  an  eclamptic  seizure. 


DISEASES  OF  THE  BRAIN. 


529 


The  diagnosis  of  this  form  of  idiocy  is  made  upon  the  abnormality 
of  the  head.  The  measurements  are  taken  of  the  head,  chest,  and 
length  of  the  infant,  and  the  relations  compared  to  those  of  the  normal 
infant  of  corresponding  age  (see  chapter  on  Development).  The 
symptoms  do  not  differ  from  those 
of  idiocy  or  imbeciht}',  as  described 
on  page  530.  The  operative  treat- 
ment of  craniotomy  which  was 
formerly  advanced  for  these  cases 
we  have  entirely  abandoned  as 
giving  no  results. 

Idiocy,  Imbecility,  Feeble- 
mindedness. 

Idiocy  may  be  divided  into 
three  groups:  the  prenatal,  the 
acquired,  and  the  myxedematous. 
In  each  of  these  the  undeveloped 
intellect  has  been  more  or  less 
permanently  impaired.  Minor 
degrees  of  idiocy  are  designated 
as  imbecility  or  feeble-minded- 
ness.  The  mental  impairment 
being  dependent  upon  the  extent 
of  the  cerebral  lesion. 

Etiology. — The  children  of  in- 
sane parents  or  of  those  who  have 

been  the  victims  of  alcoholism,  epilepsy,  hysteria,  chorea,  or  syphilis 
may  be  born  idiotic.  Consanguineous  marriages,  especially  amo^ng 
those  who  have  suffered  from  some  neurotic  disease,  may  produce 
idiotic  children.  The  acquired  types  are  generally  the  result  of 
injuries  received  at  the  time  of  birth  and  from  convulsions,  both  of 
which  result  in  the  rupture  of  delicate  blood-vessels,  with  later  sclerotic 
changes.  This  latter  change  may  also  take  place  after  attacks  of 
inflammation  of  the  brain  or  its  meninges.  The  relation  of  idiocy  to 
hydrocephalus  and  epilepsy  has  been  considered  elsewhere. 

Symptomatology. — From  the  physical  standpoint  an  idiot  may 
resemble  a  normal  child.  He  radically  differs,  however,  in  his  powers 
of  cerebration.  He  is  unable  to  acquire  any  conceptions  and  he  has 
no  sense  of  fear.  As  a  rule,  the  diagnosis  can  be  made  by  observation 
alone.  The  expression  is  vacant  and  the  eyes  are  continually  roving 
34 


iJSi.'V  ■  v'!>-^-^:-»r.';-^.-;» 

^ 

^^^^^^^^^^^B^^      jUjj^ 

1 

i'  -       ^  \ 

Fig.  14.5. 


-Microcephalus,  with  double 
hare-lip. 


530 


DISEASES  OF  CHILDREN. 


from  place  to  place.  In  younger  children  saliva  dribbles  over  the 
chin.  The  teeth  may  be  irregularly  erupted  and  usually  are  sharp 
and  carious.  Other  stigmata  of  degeneration  may  be  seen.  The 
child  cannot  distinguish  its  parents,  it  has  no  acquired  speech,  but 
makes  unintelligible  animal  sounds,  it  becomes  irritated  or  laughs 
without  provocation,  and  when  awake  keeps  in  constant  motion. 


Fig.  146. 


-Imbecile  with  marked 
strabismus. 


Fig.  147. — Idiocy,  with  blindness. 


There  are  no  habits  of  cleanliness.  Food  is  eaten  ravenously  and 
not  selected  with  any  relation  to  taste  or  desire.  Imbeciles  and 
feeble-minded  children  differ  from  idiots  in  that  they  may  be  able  to 
recognize  their  parents  and  appreciate  some  simple  objects,  as  toys. 
A  few  words  may  be  learned  and  habits  of  personal  cleanliness  may 
after  a  time  be  acquired. 

Prognosis. — The  prognosis  for  the  idiotic  child  is  invariably  bad. 


DISEASES  OF  THE  BRAIN. 


631 


The  feeble-minded  are  capable  of  some  degree  of  development  when 
placed  under  special  tuition. 

Treatment. — The  parents  of  idiots  should  be  advised  that  an 
institution  is  the  proper  place  for  their  afflicted  child,  especially  if 
there  are  other  children  in  the  family.  Here  he  will  be  unmolested  and 
allowed  more  freedom  than  is  possible  when  in  his  home. 


Fig.  148— Idiocy. 

Feeble-minded  children,  if  the  circumstances  permit,  may  be 
placed  in  institutions  arranged  for  the  care  and  training  of  mental 
defectives,  where  under  almost  private  tutelage  they  may  be  trained 
along  the  lines  in  which  they  show  any  aptitude.  In  some  of  our 
States  such  institutions  have  been  provided  for  these  unfortunates, 
so  that  even  the  children  of  the  poor  may  receive  this  beneficial  training. 


Mongolian  Idiocy. 

This  form  of  idiocy  because  of  several  simulating   features    is 
often  mistaken  for  cretinism.     The  resemblance  to  cretinism  is  seen 


532 


DISEASES  OF  CHILDREN. 


in  their  stunted  development,  in  the  large  and  often  protruded  tongue, 
the  thickened  lips,  and  open  mouth.  A  Mongolian  idiot,  however, 
may,  even  in  infancy  be  distinguished  by  the  peculiar  expression  of 
the  face,  which  when  analyzed  is  seen  to  result  from  slanting  eyelids 
like  those  seen  in  the  Mongolian  race.  Although  the  eyes  converge, 
they  are  relatively  further  apart  than  in  the  normal,  the  nose  is  small 
and  flat  and  the  contour  of  the  head  is  distinctly  rounded.  The  skin 
in  the  early  months  is  not  harsh  and  dry,  it  may  be  soft  and  velvety. 
A  rather  characteristic  feature  is  seen  in  the  flabby  muscles  and 


Fig.  149. — Mongolian  idiocy. 


mobility  of  the  joints,  which  allow  the  thighs,  for  example,  to  be 
flexed  with  extraordinary  ease  upon  the  body.  The  head  is  not  held 
erect  until  the  age  is  well  advanced,  the  fontanels  remain  open  late 
and  the  nutrition  is  impoverished  in  spite  of  good  feeding.  The  bones 
of  the  hands  and  wrists  show  deviations  from  the  normal  which  are 
best  seen  in  a  radiograph,  although  the  incurvation  of  the  little  finger 
and  the  short  second  phalanx  is  often  easily  discernible. 

The  mongoloid  idiots  further  differ  from  the  cretins  in  that  they 
are  not  influenced  by  thyroid  therapy,  and  if  they  pass  through  the 
period  of  infancy  the}'  may  show  some  degree  of  intelligence. 


DISEASES  OF  THE  BRAIN.  533 

Amaurotic  Family  Idiocy. 

This  is  a  disease  occurring  in  Hebrew  families  and  dependent  upon 
arrested  cerebral  development  and  characterized  by  blindness  and 
changes  in  the  region  of  the  macula  lutea. 

Tay,  an  oculist,  first  described  the  ocular  symptoms,  while 
Sachs,  in  this  country,  further  elaborated  the  clinical  and  pathological 
picture. 

Etiology. — The  causes  of  this  disease  are  still  undetermined. 
More  than  one  case  may  occur  in  the  same  family,  and  all  the  cases 
thus  far  observed  have  been  among  Hebrews. 


Fig.  150.— Amaurotic  family  idiocy.     (Sheffield.) 

Symptomatology. — The  first  symptoms  appear  about  the  sixth 
month.  Up  to  this  time  the  child  may  have  been  considered  healthy 
and  robust.  The  first  symptoms  noted  are  that  the  child  makes  no 
effort  to  hold  up  its  head,  moves  its  limbs  only  slightly,  and  takes  no 
interest  in  those  about  him.  If  some  degree  of  nystagmus  is  present 
the  fact  that  the  child  is  blind  escapes  the  attention  of  the  parents  or 
even  of  the  physician.  If  seated  the  head  falls  back  and  the  lower 
extremities  give  evidences  of  complete  paralysis.  Later  in  the 
disease  spasticity  occurs  in  these  extremities  with  increase  of  the 
reflexes.  As  the  disease  advances  the  weakness  becomes  intensified, 
and  usually  after  the  first  year  there  is  total  blindness  and  evidences 


534  DISEASES  OF  CHILDREN. 

appear  of  mental  deficiency.  Strabismus  is  occasionally  observed 
and  is  usually  associated  with  the  nystagmus.  Convulsions  are  rare. 
The  hearing  may  be  abnormally  acute,  the  infant  being  startled  from 
its  apathy,  for  example,  by  clapping  the  hands.  Ophthalmoscopic 
examination  fixes  the  diagnosis  when  Tay-Kingdon's  cherry-red  spots 
on  a  white  background  is  found  in  the  region  of  the  macula  lutea. 
Subsequently,  optic  nerve  atrophy  results.  Before  the  fatal  ending 
emaciation  and  other  subjective  and  objective  symptoms  of  marasmus 
appear.  The  prognosis  is  invariably  bad,  the  children  rarely  living 
beyond  the  second  year. 

Treatment. — Beyond  giving  the  prognosis  as  to  the  duration  of 
life  we  are  powerless  to  give  aid  in  this  disease. 


SECTION  XIV. 

CONGENITAL  MALFORMATIONS  AND 
DEFORMITIES. 


CHAPTER  XL. 

CONGENITAL  MALFORMATIONS  AND   DEFORMITIES. 

A  careful  examination  should  always  be  made  of  the  newly-born 
child.  Any  deviation  from  the  normal  condition  may  be  due  to  pre- 
natal malformations,  as  well  as  to  injuries  received  during  the  process 
of  birth. 

Tongue-Tie. 

A  short  frenum  causes  this  deformity.  The  tip  of  the  tongue 
is  depressed  and  fixed  in  the  floor  of  the  mouth  so  that  often  it  cannot 
be  protruded.  Sucking  and  articulation  are  difficult,  and  when 
allowed  to  persist  there  is  often  a  lisp  in  the  speech. 

The  treatment  is  surgical,  and  consists  in  dividing  the  frenum 
with  blunt  scissors  and  stripping  back  the  divided  tissue  with  the 
finger-nail.  Parents  often  attribute  backwardness  in  talking  to  a 
possible  tongue-tie.  Mental  defects  or  deafness  may  instead  be  found 
as  the  real  cause  if  the  child  is  much  beyond  the  age  when  it  showed 
be  talking. 

Harelip. 

When  the  central  process  fails  to  fuse  with  the  lateral  processes 
which  go  to  make  up  the  upper  half  of  the  face  in  fetal  life,  a  condition 
known  as  harelip  results.  This  may  be  unilateral  or  bilateral,  the 
fissure  varying  in  extent  from  a  slight  cleft  to  a  fissure  extending 
through  the  entire  length  of  the  hp  into  the  nasal  fossa. 

The  treatment  is  surgical,  and  should  be  undertaken  as  soon  as 
possible  after  the  child  is  well  started  in  its  feeding— three  months  of 
age  being  the  time  selected  by  the  majority  of  surgeons.  Nursing 
is  sometimes  impossible,  but  the  maternal  milk  should  be  pumped  out 
and  fed  by  the  dropper  or  the  Breck  feeder  (see  Fig.  3).  A  nipple 
shield  can  sometimes  be  used  to  advantage,  or  the  milk  can  be  fed 

535 


536  DISEASES  OF  CHILDREN. 

from  a  nursing  bottle  when  the  babe  cannot  suckle  the  mother's 
breast.  Nursing  should  not  be  discontinued  except  for  exceptionally 
good  reasons. 

Cleft  Palate. 

In  this  condition  a  fissure  is  seen  in  the  roof  of  the  mouth,  in- 
volving the  soft  palate,  the  hard  palate,  or  both. 

It  occurs  when  the  palatal  arches  in  fetal  life  fail  to  fuse.  Cleft 
palate  often  occurs  with  harelip,  particularly  when  the  latter  con- 
dition is  double. 

Owing  to  the  gap  in  the  mouth  the  infant  usually  cannot  nurse 
nor  feed  from  a  bottle,  and  it  is  often  necessary  to  resort  to  feeding 
with  a  dropper  or  by  gavage.  Nipples  with  a  flexible  wing  have  been 
devised  to  accommodate  these  cases  for  bottle  feeding,  the  flap  being 
so  arranged  that  it  fits  snugly  to  the  upper  lip  and  covering  the  cleft. 

Such  deformities  as  cleft  palate  and  harelip  make  feeding  very 
difficult,  and  these  cases  frequently  die  of  inanition. 

The  treatment  is  surgical;  the  operation  should  be  performed 
as  early  as  possible.  The  surgeon  who  is  to  operate  must  decide  upon 
the  preferred  age,  which  depends  upon  the  character  of  the  operation 
and  'the  nutrition  of  the  child.  Some  surgeons  operate  at  the  end  of 
the  second  year,  while  others  prefer  to  wait  until  the  arches  are  well 
developed. 

Congenital  Branchial  Cysts. 

Certain  tumors  of  the  neck  in  infants  and  young  children  have 
their  origin  in  an  incomplete  closure  of  one  of  the  branchial  clefts. 
Early  in  the  fetal  life  of  the  vertebrata  there  appears  under  the  pro- 
jecting frontal  process  a  series  of  four  plates,  bounding  the  cavity  of 
the  pharynx  on  the  side.  These  plates  unite  to  form  four  parallel 
arches  separated  by  transverse  clefts.  The  branchial  clefts  unite,  and 
by  a  process  of  morphological  change  form  various  structures  of  the 
neck.  If  this  regular  process  of  development  is  interfered  with 
from  any  cause,  various  abnormalities  may  result,  as  a  condition 
intended  to  be  merely  temporary  remains  more  or  less  permanent. 
Hence,  according  to  the  various  grades  of  arrested  development,  we 
may  have  marked  deformities,  branchial  cysts,  or  the  remains  of  fetal 
epithelial  tissue  destined  to  proliferate  at  a  later  day  and  form  a  cyst. 
There  likewise  may  result  fistulous  tracts  from  non-union  of  the 
branchial  clefts,  particularly  from  the  lowest  one.  These  have  been 
divided  into:  (a)  complete  branchial  fistulae,  open  the  whole  length  of 


CONGENITAL  MALFORMATIONS  AND  DEFORMITIES. 


537 


the  tract;  (b)  fistulae  having  only  an  external  orifice  and  ending  in  a 
cul-de-sac,  which  is  the  commonest  form;  (c)  fistulae  with  only  an  inter- 
nal orifice.  More  frequently  the  branchial  tract  is  closed  at  both  the 
pharyngeal  and  cutaneous  ends,  and  a  cyst  is  formed  between. 

Senn  has  made  the  following  classification  according  to  the  cystic 
contents:  1.  Mucous  branchial  cysts,  due  to  imperfect  closure  of  the 
upper  portion  of  the  branchial  tract  with  retention  of  its  physiological 
secretion.  2.  Atheromatous  branchial  cysts,  usually  located  in  the 
second  and  third  branchial  tracts  in  the  region  of  the  hyoid  bone.     3. 


Fig.  151. — Branchial  cyst  in  an  infant. 


Fig.  152. — Branchial  cyst  in  a  boy 
8  years  old. 


Serous  branchial  cysts,  having  a  thin-walled  capsule  lined  with  pave- 
ment epithelium,  and  following  the  defective  obliteration  of  any  of 
the  branchial  clefts.  4.  Hemato-cysts  of  branchial  clefts,  in  which 
the  serous  fluid  of  the  cyst  has  been  discolored  by  hemorrhages  into 
the  sac. 

The  contents  of  these  cysts  are  always  such  as  may  be  produced 
by  some  kind  of  epithelium,  and  in  this  they  differ  from  true  dermoid 
cysts  that  may  contain  the  secretion  of  the  various  glands  and  append- 
ages of  the  skin. 

The  two  illustrations  show  branchial  cysts  in  an  infant  five  days 
old  and  in  a  boy  of  eight  years  (Figs.  151  and  152). 

Treatment. — The  object  of  treatment  in  these  cases  is,  of  course, 


538  DISEASES  OF  CHILDREN. 

to  radically  destroy  the  membrane  that  secretes  the  serous  contents 
of  the  tumor.  In  structure,  the  cyst  consists  of  a  thin  capsule  of 
connective  tissue,  lined  on  its  inner  surface  by  a  matrix  of  epithelial 
cells,  which  must  be  destroyed  by  an  inflammation  set  up  in  the  sac 
or  removed  by  the  knife,  before  recovery  can  take  place.  As  these 
cysts  may  be  connected  with  the  sheath  of  the  deep  cervical  vessels, 
complete  removal  by  operation  may  be  attended  by  severe  hemorrhage 
unless  very  great  care  is  exercised.  When  fistulas  exist,  they  may  be 
destroyed  by  passing  in  a  probe  which  has  been  dipped  in  a  10  per 
cent,  nitrate  of  silver  solution.  If  excision  of  the  cyst  is  not  feasible^ 
it  may  be  opened  and  packed  with  gauze. 

Malformations  of  the  Esophagus. 

This  malformation  is  quite  rare.  The  diagnosis  is  generally 
made  probable  by  the  inability  of  the  infant  to  take  or  retain  any 
feedings,  or  the  return  of  such  feedings  through  fistulous  tracts. 
The  stomach-tube  cannot  be  passed  at  all  or  meets  an  obstruction  or 
stricture. 

Various  degrees  of  malformation  occur,  such  as  narrowing  in  its 
entire  length,  leaving  only  a  band-like  process,  openings  into  the 
trachea  or  externally  into  the  neck.  Blind  pouches  also  have  been 
found. 

Treatment. — Skilled  surgical  treatment  may  avail  in  the  minor 
degrees  of  malformation,  but  the  early  age  and  severity  of  the  operative 
work  mitigate  against  success  where  prolonged  procedures  are 
necessary. 

Malformations  of  the  Rectum  and  Anus. 

A  stenosis  of  the  anus  may  be  present,  due  to  abnormal  encroach- 
ment of  the  skin  upon  the  anal  mucocutaneous  tissue.  The  rectum 
itself  may  be  congenitally  too  narrow. 

The  treatment  of  both  these  conditions  is  mechanical  dilatation 
with  the  fingers  or  a  bougie. 

The  anus  may  be  imperforate  due  to  non-absorption  of  the  cuta- 
neous envelope,  the  integrity  of  the  rectum  being  normal.  Treat- 
ment of  the  abnormality  is  by  incision  and  removal  of  the  obstructing 
tissue. 

There  may  be  an  obstruction  in  the  rectum,  the  anal  structure 
being  normal;  that  is,  the  large  intestine  may  terminate  in  a  blind 
sac  having  no  communication  with  the  anus,  or  it  may  have  a  small 
fistulous    connection.     Occasionally    there  is   a  membranous    velum 


CONGENITAL  MALFORMATIONS  AND  DEFORMITIES. 


539 


with  a  very  small  aperture  across  the  rectum.  The  treatment  is 
surgical.  Careful  inspection  and  examination  of  the  newly-born 
by  the  attendant  will  reveal  the  deformity,  and  immediate  steps  should 
be  taken  to  obtain  surgical  correction. 

The  time  of  the  passage  of  the  first  stool  and  its  size  and  character 
should  always  be  investigated  by  the  attending  physician.  Minor 
degrees  of  stenosis  of  the  rectum  or  anus  are  not  infrequent  in  the  newly 
born.  Although  the  thin  feces  of  infancy  may  escape  without  diffi- 
culty, when  the  child  grows  older  and  the  excreta  become  more  solid 
stenosis  may  occasion  much  inconvenience. 


Fig.  153. — Hypospadias. 


Hypospadias. 

The  anomaly  in  male  genital  organs  in  which  the  urethra  opens  on 
the  under  surface  of  the  penis  instead  of  at  the  point  of  the  glans,  is 
known  as  hypospadias.  This  exit  may  be  located  at  any  point  on  the 
penis  from  tip  to  base,  and  is  designated  according  to  location,  as 
glandular,  penile,  peniscrotal,  or  perineal.  In  the  perineal  type, 
hermaphrodism  may  be  suspected,  as  the  testicles  are  often  unde- 
scended, the  penis  rudimentary,  and  the  scrotum  divided  by  a  deep 
fissure. 

The  passage  of  urine  is  usually  difficult.  Dripping  of  urine  from 
an  overdistended  bladder  is  the  cause  of  incontinence  in  these  cases. 


540  DISEASES  OF  CHILDREN. 

The  treatment  of  hypospadias  is  surgical  and  often  is  tedious,  but  ex- 
perienced operators  now  obtain  very  satisfactory  results  with  flap- 
method  operations. 

Extrcphy  (Ectopia)  of  the  Bladder. 

This  deformity  is  characterized  by  Ahlfeld  as  "a,  fissure  in  the 
abdomen  of  an  otherwise  well-formed  fetus,  which  is  lined  with  a  bright 
red,  velvet-like  skin  (the  bladder  membrane),  and  which  is  constantly 


Fig.  154.— Extrophy  of  the  bladder. 

kept  moist  by  the  urine  which  trickles  upon  it.  Below  the  fissure, 
in  the  abdomen  and  bladder,  are  to  be  seen  incompletely  developed 
external  genitals." 

The  only  treatment  is  plastic  surgery,  and  the  results  are  often 
quite  brilliant,  although  several  operations  are  usually  necessary 
before  a  satisfactory  repair  is  made. 

Congenital  Dislocation  of  the  Hip. 

The  cause  of  this  deformity  is  not  known,  but  some  cases  are 
doubtless  due  to  fibroid  tumors  in  the  uterine  wall  producing  a  mal- 
position in  utero.  Lange  distinguishes  three  forms:  the  supracoty- 
loid,  the  supracotyloid  and  ihac,  and  the  iHac. 

The  condition  is  rarely  noted  in  early  infancy,  as  the  symptoms  are 


CONGENITAL  iLA.LFOR»L\TIONS  AND  DEFORMITIES. 


541 


not  in  evidence  until  the  patient  begins  to  walk.  The  leg  is  short- 
ened and  flexed  on  the  pelvis,  and  when  the  dislocation  is  bilateral 
there  is  a  considerable  lordosis  present  when  the  patient  stands  erect. 
If  the  dislocation  be  unilateral  a  scoliosis  results.  A  peculiar  waddling 
gait  is  quite  characteristic  of  these  cases.  When  there  is  much  con- 
traction of  the  adductors  the  lower  ends  of  the  femurs  cross  each 
other,  forming  the  scissor-leg  deform- 
ity. This,  however,  is  rare.  A  Roent- 
gen photograph  will  clear  up  any 
question  as  to  the  diagnosis.  A  re- 
duction of  the'  dislocation  is  more 
readily  made  when  the  patients  have 
not  done  much  walking,  as  owing  to 
the  shallow  acetabulum  it  is  impossi- 
ble to  keep  the  femoral  head  in  place 
unless  the  patient  remains  in  bed. 

Treatment. — The  bloodless  re- 
duction method  advocated  by  Lorenz 
is  usually  selected  by  the  surgeon  as 
offering  the  best  results.  A  plaster 
dressing  is  applied  which  must  be 
worn  for  months,  and  later  massage 
and  exercises  are  ordered.  This 
operation  should  not  be  delayed  too 
long,  as  in  older  children  good  results 
are  rarely  secured. 

Congenital  Absence  of  the  Bones. 

Among  the  rarer  bony  deformities  there  is  occasionally  seen  an  ab- 
sence of  the  radius.  This  is  a  bilateral  defect,  and  produces  a  serious 
incapacity  in  the  physical  strength  and  ability  of  the  extremity  af- 
fected. An  incurvation  due  to  abnormal  muscular  attachments 
results,  as  illustrated  in  the  radiograph  (Fig.  158). 

Fig.  155  is  a  radiograph  showing  absence  of  the  greater  portion 
of  the  phalanges. 

Fig.  157  shows  an  absence  of  the  hands  beyond  the  carpals  as  a 
result  of  intrauterine  amputation. 

Talipes. 

(Club-foot.) 
■    Congenital  talipes  results  from  malformation  or  lack  of  develop- 
ment of  the  bones  about  the  ankle. 


Fig.  155. — Congenital  deformity 
of  the  hand. 


A  small  uterus  with  deficient 


542  DISEASES  OF  CHILDREN. 

liquor  amnii  may  produce  a  talipes  by  abnormally  compressing  the 
parts,  the  normal  position  of  the  feet  in  utero  being  a  talipes  varus. 

All  acquired  talipes  are  due  to  pathological  conditions;  for  example, 
following  anterior  poliomyelitis  or  contractions  of  tissues  after  exten- 
sive burns  or  diffuse  suppurations,  and  as  the  result  of  the  overaction 
of  certain  muscle  groups  when  the  nerve  trunk  supplying  their  equilib- 
rants  is  affected. 


Fig.  156. — Double  congenital  dis-         Fig.    157.— Intra-uterine   amputation 
location  of  the  hip.  of  the  hands. 


In  fact,  any  process  which  will  change  the  normal  equilibrium  of 
muscle  groups  about  the  ankle  will  produce  a  talipes.  The  cause 
may  be  found  in  the  bony  or  ligamentous  structures  or  in  the  muscles. 

Talipes  varus  is  the  most  frequent  variety  seen  in  congenital  cases. 
In  this  form  the  patient  walks  on  the  outer  surface  of  the  ankle,  the 
inner  surface  of  the  foot  being  raised. 

Talipes  equinus  results  when  the  heel  is  elevated  and  the  patient 
walks  on  his  toes.  This  form  results  from  paralysis  of  the  extensor 
muscles  of  the  leg  with  secondary  contractions  of  the  muscles  of  the 


CONGENITAL  MALFORMATIONS  AND  DEFORMITIES. 


543 


calf,  and  occurs  following  anterior  poliomyelitis  or  injuries  to  the 
anterior  tibial  nerve. 

In  talipes  valgus  the  patient  walks  on  the  inner  surface  of  the 
ankle,  the  outer  border  of  the  foot  being  raised  and  everted.  A 
paralysis  of  the  tibial  muscles  produces  this  deformity. 

Talipes  calcaneous  is  rare;  the  patient  walks  on  his  heel  with  the 
toes  elevated.  This  deformity  arises  when  the  calf  muscles  are 
paralized. 


Fig.  158.— Congenital  absence  of  the  radius. 

Treatment. — In  congenital  cases  daily  manipulation  of  the  foot 
and  ankle  should  be  instituted  at  once  until  the  deformity  is 
overcorrected,  the  foot  being  retained  in  good  position  by  mechanical 
means  such  as  a  cast  or  apparatus. 

In  paralytic  cases  manipulation  and  massage  is  indicated,  special 
attention  being  given  to  the  weakened  muscle  groups,  toning  them  up 
by  the  use  of  faradism  and  friction.  A  proper  splint  should  be  applied 
to  retain  the  foot  and  ankle  in  the  correct  position.  Tenotomy  and 
other  operative  measures  may  be  necessary  in  neglected  cases. 


544 


DISEASES  OF  CHILDREN. 


Webbed  Fingers  and  Toes. 

^  (Syndactylism.) 

In  this  condition  two  or  more  fingers  or  toes  are  joined  laterally 
by  a  web  which,  if  thin,  consists  mainly  of  skin,  but  if  thick  more  or 
less  fleshy  tissue  is  present.  If  the  fingers  be  affected,  the  web  must 
be  divided,  care  being  taken  to  insure  full  separation  to  the  base  of  the 
fingers  and  the  separation  maintained.  If  the  web  be  thin  the  oper- 
ation consists  in  incision  only;  but  if  the  web  be  fleshy,  skin  flaps 
must  be  made  and  the  denuded  surfaces  covered.  Webbed  toes 
need  not  to  be  treated  unless  for  the  cosmetic  effect. 


Fig.  15!). — Congenital  club  feet  in  an  infant  with  a  spina  bifida. 


Meningocele  and  Encephalocele. 

Owing  to  a  congenital  opening  at  some  part  of  the  skull,  a  portion 
of  the  cranial  contents  ma}^  protrude.  The  defect  is  most  common  in 
the  occipital  bone,  in  any  portion  of  which  the  defect  may  be  present, 
from  the  peripheral  part  to  the  center.     If  it  exists  in  the  anterior 


CONGENITAL  MALFORMATIONS  AND  DEFORMITIES, 


545 


portion  of  the  bone,  it  may  extend  to  the  posterior  fontanel;  if  in 
the  back  part,  it  may  connect  with  the  foramen  magnum.  The  size 
of  the  tumor  depends,  of  course,  upon  the  extent  of  the  opening  in 


Fig.  160. — Webbed  fingers. 

the  bone.  Similar  defects  may  also  be  present  in  the  nasofrontal 
region,  and  less  frequently  in  the  basilar,  temporal,  and  parietal  seg- 
ments of  the  skull.     The  openings  may  contain  meninges  alone,  men- 


Fit,.  161. — Supernumerary  thumb. 

inges  with  brain  matter,  or  the  latter  with  fluid  in  the  interior;  in 
the   latter   event   the   anomaly   is   termed    hydrencephalocele.     The 
tumors  appear  at  or  soon  after  birth. 
35 


546 


DISEASES  OF  CHILDREN, 


A  meningocele  is  usually  small,  with  little  tendency  to  increase  in 
size.  It  may  be  more  or  less  pedunculated:  it  presents  fluctuation, 
but  no  pulsation,  and  is  usually  reducible. 

In  encephalocele  there  is  distinct  pulsation,  and  efforts  at  com- 
pression will  be  accompanied  with  evidences  of  marked  cerebral 
irritation.  The  tumor,  though  not  large,  has  a  wide  base,  and  is 
partly  reducible. 

A  hydrencephalocele  is  apt  to  be  large,  lobulated,  with  sometimes 
a  distinct  peduncle.     Pulsation  is  usually  absent  in  the  tumor,  which, 


Fig.  162. — Meningocele. 

however,  is  fluctuating  and  mostly  translucent.  Compression  is  not 
apt  to  be  successful  in  reducing  the  tumor.  Sometimes  there  is  more 
brain  substance  in  the  tumor  than  in  the  cranial  cavity,  and  the  infant 
is  then  microcephalic. 

Prognosis. — The  prognosis  in  hydrencephalocele  is  bad,  as  the 
tumor  usually  grows  rapidly,  and  there  may  be  rupture,  with  im- 
mediate death.  In  meningocele  and  encephalocele  the  prognosis  is 
better,  especially  if  the  tumor  be  small. 

Treatment. — Treatment  in  these  cases  is  of  little  avail,  although 
the  withdrawal  of  fluid  and  even  stimulating  injections  have  been  tried. 


CONGENITAL  MALFORMATIONS  AXD  DEFORMITIES. 


547 


Spina  Bifida. 

Owing  to  congenital  failure  in  the  development  of  the  vertebral 
arch,  one  or  more  of  the  laminae  may  be  absent,  with  resulting  pro- 
trusion of  the  spinal  meninges.  The  lumbar  region  of  the  spinal 
column  is  the  part  usually  affected.  Occasionally,  however,  we  have 
meningocele  or  encephalocele.  The  tumor  is  round,  fluctuating,  and 
by  compression  the  cerebrospinal  fluid  can  be  forced  back  into  the 
spinal  canal.  Too  severe  pressure,  however,  may  produce  eclampsia 
or  other  grave  cerebral  symptoms. 
The  base  of  the  tumor  depends  upon 
the  size  of  the  opening,  being  pedun- 
culated if  it  is  small,  but  more  sessile 
if  large.  The  tumor  is  usually  covered 
with  skin,  which,  however,  may  be 
absent,  exposing  the  dura  mater.  If 
there  is  not  much  tissue  covering 
the  tumor,  transudation  may  occur 
through  the  walls  or  rupture  of  the 
sac  may  take  place  if  growth  is  rapid. 
Some  portion  of  the  lower  segment  of 
the  cord  or  the  cauda  equina  is  apt  to 
be  imprisoned  in  the  sac.  The  extent 
of  the  involvement  of  nerve-tissue  can 
be  measured  by  the  paraplegia  or 
othei'  evidences  of  lesion  in  the  spinal 
cord  and  nerves. 

Gradual  absorption  of  the  fluid 
may  occur,  and  the  child  may  grow 
up  with  little  inconvenience  from  the 
shrivelled  tumor.  This,  of  course, 
takes  place  only  when  the  nerves  are 
not  involved.  In  most  cases  there  is 
a  gradual  increase  in  the  size  of  the  tumor,  with  final  ulceration  or 
rupture,  followed  by  convulsions  or  coma  and  death.  The  fatal  ending 
may  also  come  with  a  gradual  emaciation  accompanying  paraplegia. 

Treatment. — The  treatment  of  small  tumors  consists  in  the 
application  of  a  soft  compress  to  avoid  friction  and  to  support  the 
parts.  When  the  tumor  is  growing,  however,  more  energetic  measures 
may  be  tried.  The  simplest  procedure  is  to  withdraw  the  fluid  by 
aspiration,  and  follow  this  with  gentle  but  constant  pressure.  The 
fluid  must  be  slowly  and  cautiously  removed,  for  fear  of  active  nervous 


Fig.  163. — Spina  bifida. 


548  DISEASES  OF  CHILDREN. 

disturbance  and  even  eclampsia.  Injections  with  iodin  of  various 
strengths  have  been  tried,  but  without  much  success.  In  some  cases 
the  tumor  can  be  surgically  removed  by  completely  excising  the  sac. 
This  may  be  successfully  accomplished  in  the  pedunculated  variety 
where  the  opening  in  the  lamina  is  small.  It  should  never  be  attemped 
if  there  is  evidence  that  the  cord  or  cauda  equina  may  be  involved  in 
the  tumor. 


SECTION  XV. 
THE  COMMONER  SURGICAL  DISEASES. 


CHAPTER  XLI. 

THE  COMMONER  SURGICAL  DISEASES. 

Anesthesia. 

The  administration  of  an  anesthetic  to  a  child  is  often  rightly 
viewed  with  apprehension  by  the  practitioner,  and  questions  arise 
as  to  the  best  method  and  safest  anesthetic  to  employ. 

The  same  phenomena  are  observed  in  early  life  as  in  adults,  but 
the  margin  of  safety  is  less,  and  thus  the  use  of  any  anesthetic  should 
be  regarded  as  a  factor  by  itself  and  given  the  consideration  it  de- 
serves in  relation  to  the  age,  the  physical  condition  of  the  patient, 
and  the  character  of  the  operation  he  is  to  undergo.  It  should  be 
recollected  that  any  anesthetic  given  beyond  its  proper  limits  is  a 
cardiac  depressant. 

Choice  of  Anesthetic. — Ether  is  preferable  if  the  anesthetist  is  not 
thoroughly  experienced;  if  the  period  of  insensibility  is  to  be  a  long 
one;  in  cardiac  diseases  and  in  operations  for  the  relief  of  obstructed 
respiration,  as  Ludwig's  angina,  papillomata  of  the  larynx  or  deep 
cervical  adenitis.  It  is  also  to  be  preferred  if  the  patient  must  be  kept 
in  an  erect  or  semi-erect  posture. 

Chloroform  in  the  hands  of  an  expert  in  anesthesia  is  preferable 
to  ether.  Children  are  rapidly  brought  under  its  influence  as  they 
usually  cry  and  thus  inspire  rapidly.  Plenty  of  air,  constant  vigilance, 
and  the  utilization  of  the  drop-by-drop  method,  depending  on  each 
minim  administered  to  add  to  the  effect,  is  the  proper  procedure. 

In  minor  surgical  affections  in  which  only  a  primary  anesthesia 
is  required,  chloroform  is  of  advantage,  as  the  patient  rapidly  comes 
out  of  its  influence  without  the  nausea  and  vomiting  which  are  so 
often  seen  with  ether.  Chloroform  is  preferable  if  nephritic  condi- 
tions are  present,  or  a  possibiHty,  as  in  suppurative  adenitis  following 
scarlatina.  Lividity  of  the  lips,  with  an  ashen-pale  face  and  weak 
slow  pulse  are  indications  that  should  be  met  by  immediately  stop- 
ping the  anesthetic,  inducing  free  respirations  and  by  hypodermatic 
stimulation. 

549 


550  DISEASES  OF  CHILDREN. 

Gas-ether  anesthesia,  in  the  hands  of  professional  anesthetists, 
is  the  method  to  be  selected  for  older  children,  but  in  infancy  and 
the  first  years  of  life  the  nitrous  oxid  gas  is  poorly  borne  and  liable  to 
cause  suffocative  cyanosis. 

Anesthesia,  according  to  the  method  of  Schleich,  or  the  spray 
method  with  ethyl  chlorid  are  satisfactory  in  the  hands  of  those  accus- 
tomed to  them,  but  cannot  be  commended  for  general  use. 

Preparation  for  Anesthesia. — Feeble  children  should  not  be  denied 
food  for  a  longer  period  than  three  or  four  hours  before  administering 
the  anesthetic.  Often  a  small  amount  of  a  hot  liquid,  such  as  thin 
gruel,  will  be  effective  in  preventing  collapse  of  the  infant.  The  bowels 
should  be  moved  by  a  soap-suds  enema,  and  in  older  children  a  dram 
or  two  of  licorice  powder  should  be  given  the  night  before.  As  the 
bodily  heat  is  easily  dissipated,  especially  in  infants,  they  should  not 
be  unduly  uncovered,  and  artificial  heat  may  be  applied  during  the 
operation  with  favorable  effect.  A  preliminary  stomach  washing  in 
cases  of  intestinal  obstruction  with  incessant  vomiting  should  precede 
the  operation.  Hopodermocylsis  and  a  nutrient  enema  may  also  be 
indicated  in  certain  feeble  or  anemic  infants  in  whom  collapse  is  feared. 

Hernia  in  Early  Life. 

Hernia  occurs  in  young  children  as  a  result  of  arrest  or  defective 
development  of  the  fetus,  which  allows  the  protrusion  of  some  of 
the  abdominal  contents  through  a  natural  opening. 

Etiology. — Hernia  in  early  life  may  be  in  the  order  of  their  fre- 
quency, inguinal,  umbilical,  ventral,  and  femoral. 

Inguinal  hernia  occurs  more  commonly  in  boys  than  in  girls,  and 
we  are  inclined  to  agree  with  Russell  that  this  form  is  essentially  due 
to  a  preformed  sac  or  an  obliterated  portion  of  the  vaginal  process. 
Such  a  sac  results  when  a  part  of  the  peritoneum  coming  down  in 
front  of  the  testicle  as  it  passes  into  the  scrotum  in  fetal  life  fails  to  be 
obliterated  and  separated  from  the  remainder  of  the  peritoneal  cavity. 
Thus  oblique  or  indirect  hernia  is  congenitally  formed.  Coley  sug- 
gests that  the  terms  "congenital"  and  "acquired"  be  abandoned 
and  that  we  adopt  instead  the  classification  of  total  or  partial  funicular 
sacs.  Direct  and  femoral  hernias  are  in  the  majority  of  cases  acquired, 
as  they  rarely  result  from  congenital  sacs. 

The  most  common  predisposing  causes  other  than  the  anatomic  are 
constipation,  pertussis,  tympanites,  crying,  straining,  and  coughing. 

Symptomatology. — The  signs  do  not  differ  very  materially  from 
those  found  in  the  adult.     A  tumor  may  appear  and  reappear  several 


THE  COMMONER  SURGICAL  DISEASES.  551 

times  before  attention  is  directed  to  it.  The  tumor  gives  an  impulse 
to  the  finger  on  crying  or  laughing;  it  may  disappear  spontaneously 
on  lying  down,  it  may  cause  discomfort  or  even  pain  at  this  time  of  life, 
and  if  the  intestine  has  protruded  a  sensation  of  gurgling  is  felt  when 
the  tumor  contents  slip  into  the  abdominal  cavity.  Strangulation  is 
not  common,  and  when  it  occurs  results  from  constriction  at  the  exter- 
nal abdominal  ring,  from  tough  and  inelastic  fibrous  bands  or  rings 
which  may  be  found  within  the  sac  (De  Garmo)  or  from  fecal  impac- 
tion. The  symptoms  of  this  complication  are,  besides  the  tumor  itself, 
nausea  and  vomiting,  constipation  with  abdominal  distention,  pains 
of  a  colicky  character  which  are  increased  on  urination,  increased  pulse 
rate,  a  variable  amount  of  temperature,  restlessness,  and  if  relief  is 
not  obtained  at  this  point  vomiting  becomes  stercoraceous  with  sub- 
normal temperature,  and  a  fatal  issue  will  result. 

Diagnosis. — The  differential  diagnosis  is  given  on  page  478. 

Treatment. — The  great  majority  of  children  under  three  years  of 
age  can  be  cured  by  mechanical  means.  This  implies  the  proper  ap- 
plication of  a  suitable  truss.  This  should  be  made  of  hard  rubber  with 
a  slightly  convex  pad  of  the  same  material,  or  consist  of  a  water  pad 
covered  with  impervious,  water-proof  material.  These  are  recom- 
mended because  they  can  be  readily  adjusted  and  kept  clean.  Leather 
trusses  soon  become  soiled  or  soaked  with  urine  and  produce  excoria- 
tion. The  physician  himself  should  select  and  fit  the  truss,  the  spring 
should  be  just  strong  enough  to  properly  retain  the  hernia  even  when 
the  child  cries  or  strains.  It  should  be  applied  only  in  the  prone  posi- 
tion and  worn  continually  day  and  night.  Parents  should  be  warned 
not  to  unnecessarily  remove  it  unless  the  child  is  lying  down  and  the 
hernia  meanwhile  digitally  retained.  A  cure  is  generally  affected 
within  a  year,  although  it  is  advisable  to  retain  the  support  for  a  year 
and  a  half.  If  after  this  time  the  tumor  still  protrudes  on  exertion, 
recourse  must  be  had  to  operation. 

Children  over  six  years  of  age  are  rarely,  if  ever,  cured  by  the 
application  of  a  truss. 

The  treatment  of  umbilical  hernia  has  been  discussed  and  illus- 
trated on  page  16.  Operation  is  indicated  immediately  in  all  cases 
of  strangulated  hernia.  It  is  necessary  in  hernia  complicated  with 
irreducible  hydrocele,  in  femoral  hernias,  and  in  children  over  four 
years  of  age  who  have  not  been  cured  by  the  application  of  a  properly 
fitted  truss  worn  over  the  prescribed  period. 

The  Bassini  operation,  which  is  founded  upon  the  etiological  factors 
involved  in  the  production  of  hernia,  almost  invariably  gives  most 
satisfactorv  results  in  competent  hands. 


552  DISEASES  OF  CHILDREN. 


Circumcision. 


Many  male  infants  need  circumcision.  The  operation  promotes 
cleanliness  and  inhibits  the  formation  of  the  habit  of  masturbation. 

In  cases  in  which  the  adhesions  about  the  glans  penis  have  been 
separated  and  the  prepuce  still  does  not  sufficiently  retract,  circum- 
cision is  indicated.  It  is  certainly  necessary  in  all  cases  in  which  the 
prepuce  is  tight  enough  to  hold  drops  of  urine  or  when  it  balloons 
out  on  urination.  The  prepuce  should  be  so  trimmed  that  the  corona 
is  covered  and  only  enough  should  be  cut  away  so  that  the  prepuce 
can  move  freely  over  the  glans.  In  this  way  its  physiological  purpose 
will  be  preserved. 

This  operation  should  be  performed  in  the  early  months  of  life. 
It  should  be  unnecessary  to  say  that  surgical  cleanliness  is  to  be  ob- 
served. With  a  pair  of  hemostatic  forceps  stretch  the  prepuce,  and 
insert  a  director  between  it  and  the  glans.  Then  incise  along  the  dor- 
sum in  the  middle  line  to  a  point  just  proximal  to  the  corona.  Sepa- 
rate all  adhesions  until  the  coronal  sulcus  is  defined  and  remove  all 
smegma.  Cut  away  the  redundant  tissue,  including  both  skin  and 
mucous  membrane  from  both  sides  down  the  frenum.  After  all  the 
edges  have  been  carefully  trimmed  put  in  three  or  four  fine  plain  cat- 
gut sutures  to  prevent  any  exposure  of  raw  surface.  Bleeding  is 
slight  and  probably  no  ligatures  will  be  required.  Use  plain  gauze 
strips  covered  with  sterile  vaselin  for  a  dressing.  If  the  suture  mate- 
rial used  is  non-absorbable,  remove  the  sutures  on  the  fifth  day  and 
powder  the  wound  with  aristol. 

Appendicitis. 

Etiology. — Appendicitis  is  comparatively  rare  in  early  life.  In 
infancy  it  is  extremely  uncommon.  Invasion  of  the  lymphoid  struc- 
ture of  the  appendix  by  bacteria  is  made  possible  by  traumatism  from 
within  or  without,  by  intestinal  parasites,  mucous  inclusion,  or  con- 
strictions harboring  fecal  masses. 

From  a  pathological  standpoint  the  disease  in  children  does  not 
materially  differ  from  that  found  in  the  adult.  It  should  be  recol- 
lected, however,  that  the  appendix  in  children  is  normally  not  larger 
in  diameter  than  a  goose-quill;  that  it  is  more  apt  to  be  found  in 
diverse  situations  and  that  it^normally  lies  higher  in  the  abdomen. 
Suppuration  takes  place  more  readily  and  localized  abscess  forma- 
tions are  not  unusual.     In  quite  a  nunrber  of  our  cases,  children  with 


THE    COMMONER   SURGICAL   DISEASES.  553 

appendicitis  were  willing  to  walk  about  or  sit  up  even  when  ulcerative 
conditions  were  subsequently  found  at  laparotomy. 

Symptomatology. — In  the  acute  inflammatory  form  the  child  may 
complain  of  indefinite  colicky  pains  which  are  often  attributed  by  the 
parents  to  some,  indiscretion  in  diet,  especially  when  vomiting  occurs 
early.  Thefever  is  not  high,  rarely  rising  above  102°  F.  If  the  patient 
is  walking  about,  he  usually  stoops  and  his  movements  are  made 
cautiously.  After  being  placed  in  bed  he  may  prefer  to  lie  on  his  back, 
drawing  up  the  knees  to  relax  the  abdomen.  Although  if  asked  to  do 
so  he  may  not  hesitate  to  turn  to  either  side  or  extend  the  thighs. 
The  area  of  pain  may  not  be  definitely  located  by  the  patient  in  the 
right  iliac  fossa;  in  fact,  he  very  often  refers  it  to  the  umbilical 
region. 

Examination. — On  inspection  the  contour  of  the  abdomen  is 
usually  found  to  be  normal;  there  may  be  slight  distention  observable. 
Palpation,  carefully  performed,  so  as  not  to  excite  undue  muscular 
effort  may  elicit  some  resistance  and  tenderness  in  the  right  iliac  fossa. 
In  children  it  is  seldom  that  a  definitely  localized  spot  of  tenderness 
is  found  over  McBurney's  point.  In  thin  subjects,  however,  it  may 
be  possible  to  definitely  locate  the  inflamed  appendix.  If  the  diag- 
nosis is  still  in  doubt,  bi-manual  rectal  examination  should  be  made 
according  to  the  method  described  on  page  48.  A  low  grade  of  leu- 
kocytosis .is  usually  found  in  this  type. 

Such  a  case  of  appendicitis  may  subside  under  medical  treat- 
ment, but  recurrences  are  almost  sure  to  follow  at  some  future  time 
making  the  prognosis  graver  than  if  operation  is  performed  at  once  or 
in  the  interval. 

The  suppurative  form  with  a  tendency  to  perforation  at  or  near 
the  tip  occurs  more  commonly  and  the  symptoms  are  more  severe. 
The  pain  may  come  on  suddenly  with  fever,  nausea,  and  vomiting, 
constipation  and  tympanites  occur,  the  patient  generally  seeks  his  bed 
and  is  satisfied  to  lie  quietly  in  the  recumbent  posture.  The  legs 
are  drawn  up  and  the  patient  localizes  the  pain  more  definitely  to  the 
right  iliac  fossa.  The  temperature  varies  between  101°  and  103°  F. 
and  rarely  rises  above  this  point;  the  fever  may  not  reach  higher  than 
lOr  F.  The  pulse  rate  is  increased,  especially  so  if  perforation  takes 
place.  Gangrenous  changes  may  occur  and  may  be  suspected  if 
the  subjective  or  constitutional  signs  are  more  marked. 

Examination.~On  inspection,  the  attitude  of  the  patient  with 
the  knees  drawn  up,  the  facies  showing  distress,  the  coated  tongue  and 
the  distended  abdomen  with  suppressed  abdominal  respiration  should 
be  suggestive.     On  palpation  of  the  right  side  the  muscular  rigidity 


554  DISEASES  OF  CHILDREN. 

is  marked  and  a  distinctly  painful  area  of  tenderness  may  be  mapped 
out.  In  some  cases  the  tumefaction  or  mass  can  be  quite  easily  felt. 
Rectal  examination  should  confirm  these  findings.  Repeated  blood 
examinations  will  show  varying  percentages  of  polynuclear  elements 
ranging  from  85  to  95  per  cent.  If  peritonitis  has  resulted,  the  ab- 
dominal rigidity  is  increased  and  vomiting  again  occurs,  the  abdomen 
is  distended  with  gas,  obscuring  the  liver  dullness.  When  the  peri- 
tonitis is  localized  about  the  caput  coli  the  inflamed  appendix  may  be 
walled  off  from  the  general  cavity.  This  is  indicated  by  a  diminution 
of  the  general  symptoms. 

An  abscess  may  form  within  this  area  from  perforation,  gangrene 
or  rupture  of  the  appendix.  Fluctuation  may  be  obtained,  but  even 
before  this  a  sudden  drop  in  the  temperature  curve  points  to  a  focus  of 
pus.  A  differential  leukocyte  count  will  also  act  as  corroborative  evi- 
dence when  the  percentage  of  polymorphonuclear  leukocytes  is  greater 
than  eighty. 

Diagnosis. — Cases  presenting  the  classical  symptoms  of  pain  in 
the  right  iliac  fossa  with  rigidity  of  the  right  rectus  muscle,  tumefac- 
tion, fever,  and  vomiting  should  occasion  little  or  no  difficulty  in  diag- 
nosis. Examination  under  a  general  anesthetic  may  sometimes  be 
necessary  in  doubtful  cases,  especially  if  a  skilled  surgeon  is  not  at  hand. 
Intestinal  obstruction  is  to  be  differentiated  by  the  absence  of  initial 
fever,  the  presence  of  a  palpable  sausage-shaped  mass,  tenesmus,  and 
discharges  of  blood  and  mucus. 

Not  infrequently  a  pneumonic  process  involving  the  base  of  the 
right  lung  causes  pain  which  is  referred  to  the  ileocecal  region,  and 
the  unwary  may  mistake  this  for  appendicitis. 

Prognosis. — The  tendency  toward  suppuration  and  the  develop- 
ment of  general  peritonitis  make  this  disease  a  grave  one  in  early  life. 
The  mortality,  however,  will  be  distinctly  lessened  when  early  diagnoses 
are  made  followed  by  prompt  surgical  intervention. 

Treatment. — The  medical  treatment  of  appendicitis  should  con- 
sist in  immediately  placing  the  patient  in  bed,  allowing  him  to  assume 
a  position  of  comfort.  A  hght  ice  bladder  is  placed  over  the  point  of 
greatest  tenderness.  The  bowels  should  be  moved  with  a  soap-suds 
enema.  A  liquid  diet,  consisting  of  milk,  ice  cream,  and  thin  gruels 
is  given  if  the  vomiting  permits.  The  question  of  operation  should 
be  left  to  the  judgment  of  a  competent  surgeon. 

Children  bear  the  operation  well,  and,  unless  the  circumstances 
contraindicate  it,  immediate  operation  is  to  be  preferred  to  the  chances 
of  perforation  or  general  peritonitis. 


THE  COMMONER  SURGICAL  DISEASES.  555 

Intussusception. 

(Invagination). 

This  very  frequent  form  of  intestinal  obstruction  in  children  is 
caused  by  a  prolapse  of  a  portion  of  intestine  into  the  lumen  of  the 
adjoining  bowel. 

While  other  causes,  such  as  volvulus,  Meckel's  diverticulum,  bands, 
and  foreign  bodies,  may  produce  intestinal  obstruction,  they  occur  so 
rarely  that  they  need  not  be  considered  here. 

Etiology. — We  are  inclined  to  believe  that  the  condition  can  be 
accounted  for  by  irregular  peristaltic  action  taking  place  in  a  gut, 
the  walls  of  which  are  thin  and  undeveloped  and  only  loosely  held  by 
mesentery. 

The  exciting  cause  may  be  undiscoverable.  We  have  seen  it  in 
breast-fed  infants  who  appeared  healthy  in  every  way.  Overloading 
of  the  intestine,  producing  fermentation,  colic  and  an  irritative  form  of 
diarrhea  may  induce  it.  Constipation,  tenesmus  in  the  intestinal  wall 
as  polypi,  appendicitis,  and  cathartic  drugs  have  been  held  respon- 
sible for  its  onset.  It  occurs  more  frequently  in  males  and  the  majority 
of  cases  occur  in  poorly  nourished  children  in  the  first  year  of  life. 
The  fourth  to  the  sixth  month  being  the  time  of  greatest  incidence. 

Symptomatology. — The  onset  is  sudden  and  acute  in  the  majority 
of  cases.  Only  in  such  situations  as  the  rectum  or  low  down  in  the 
colon  may  the  symptoms  come  on  at  all  gradually.  An  infant  appar- 
ently healthy  may  suddenly  begin  to  cry  violently  with  pain  which 
is  usually  regarded  as  colicky  in  nature,  the  extremities  may  be  kept 
incessantly  moving.  Vomiting  soon  occurs,  the  child's  appearance 
changes.  The  face  is  pale,  showing  marked  evidences  of  distress  and 
prostration.  The  first  movement  of  the  bowels  after  the  intussuscep- 
tion may  contain  a  single  amount  of  fecal  matter;  thereafter  the  move- 
ments consist  only  of  blood  and  mucus  which  are  passed  with  some 
tenesmus.  The  vomiting  which  is  almost  projectile  occurs  at  very 
frequent  intervals.  After  the  stomach  contents  have  been  emptied, 
bile-stained  mucus  or  even  fecal  matter  may  be  vomited  in  the  final 
stages.  There  is  little  or  no  fever,  but  the  pulse  is  extremely  rapid  and 
thready.  On  examination  of  the  abdomen  a  sausage-shaped  tumor 
may  be  felt,  which  if  firmly  palpated  may  feel  harder.  This  tumor 
may  be  found  in  different  situations,  but  generally  is  found  in  the  left 
iliac  fossa  along  the  line  of  the  colon.  Bi-manual  rectal  examination 
may  confirm  its  presence.  In  some  instances  it  may  protrude  from 
the  rectum  and  may  be  mistaken  for  a  prolapse.  It  must  not  be  for- 
gotten that  intussusception  can  occur  without  the  presence  of  a  pal- 


556  DISEASES  OF  CHILDREN. 

pable  tumor.  Sometimes  a  depression  or  flattening  in  the  opposite 
iliac  fossa  is  observed.  Unless  relief  is  obtained  the  prostration  be- 
comes more  intense,  subnormal  temperature  and  death  may  ensue  from 
exhaustion.  Cases  of  spontaneous  reduction  and  relief  by  gan- 
grenous sloughing  of  the  intussusceptum  have  been  reported,  but  are  so 
rare  as  to  merit  recognition  only  as  curiosities. 

Diagnosis. — This  may  be  founded  upon  the  following  symptoms: 
A  sudden  onset,  a  paroxysmal  colicky  pain,  vomiting,  prostration, 
discharges  of  blood  and  mucus. 

In  our  experience  dysentery  is  most  often  confounded  with  in- 
tussusception. The  presence  of  some  fecal  matter  in  the  stools, 
the  constant  fever,  and  the  moderate  vomiting  with  prostration  only 
proportionate  to  the  severity  of  the  disease,  should  distinguish  the 
conditions. 

Prognosis. — Unless  the  condition  is  promptly  recognized  and 
immediate  treatment  instituted,  a  fatal  issue  may  be  expected.  The 
mortality  statistics  vary  from  60  to  70  per  cent.  The  younger  the 
infant  the  graver  the  prognosis. 

Treatment. — An  attempt  and  only  one  should  be  made  to  reduce 
the  intussusception  if  the  diagnosis  is  quite  certain  within  a  few  hours 
after  the  onset  of  the  acute  symptoms.  It  may  then  be  successful, 
especially  if  the  invagination  is  in  the  colon. 

The  child  is  placed  on  its  back,  the  buttocks  elevated,  and  a  warm 
saline  solution  from  a  two-quart  fountain  bag,  held  four  feet  above 
the  patient,  is  allowed  to  distend  the  gut.  The  fluid  should  be  retained 
by  holding  the  buttocks  firmly  together.  A  long  large  catheter  is 
preferable  to  the  ordinary  hard-rubber  tip.  While  the  child  is  in  this 
position  gentle  manipulations  to  assist  the  reduction  may  be  made. 
If  the  result  is  successful  the  tumor  disappears  with  a  gurgling  intes- 
tinal sound.  Undue  efforts  in  this  direction  should  not  be  made.  If 
reduction  is  unsuccessful  or  the  case  of  longer  standing  immediate 
operative  interference  is  demanded.  A  preliminary  stomach  washing 
and  stimulation  hypodermatically  in  the  form  of  strychnin  or  brandy, 
will  better  prepare  the  patient  to  withstand  operative  interference. 

Acute  Peritonitis. 

In  the  New-born. — The  diagnosis  of  the  acute  forms  in  infancy  are 
too  often  made  only  at  necropsy.  This  is  so  because  of  the  uncom- 
monness  of  the  affection,  the  meager  history  obtainable,  if  any, 
the  lack  of  distinctive  physical  signs,  and  the  inability  of  the  patient 
to  relate  subjective  symptoms. 


THE  COMMONER  SURGICAL  DISEASES.  557 

Fortunately,  acute  peritonitis  is  not  a  frequent  occurrence  among 
children,  although  in  the  new-born  it  is  not  as  rare  as  it  may  be  com- 
monly supposed.  Through  the  umbilicus  pathogenic  bacteria  may 
gain  entrance  and  cause  peritoneal  infection. 

The  streptococcus  and  the  bacterium  coli  communis  can  be  held 
responsible  for  the  majority  of  the  cases  occurring  in  the  new-born. 
When  a  general  sepsis  results  the  diagnosis  is  not  as  difficult  as  when 
the  infection  is  localized  in  the  peritoneum. 

Symptomatology. — In  the  new-born,  the  disease  must  be  considered 
when  there  is  a  locaHzed  umbihcal  infection  followed  by  a  sudden 
abrupt  change  in  the  infant's  condition.  The  extremely  rapid  gasping 
breathing  may  first  attract  the  attention  of  the  attendant.  The  in- 
fant cannot  or  will  not  nurse,  the  temperature  is  persistently  high, 
104°  to  105°  F.  with  a  rapid  weak  pulse.  The  position  assumed  by 
the  infant  is  one  of  tension.  Its  legs  are  drawn  up  and  pain  is  sharply 
elicited  by  attempts  to  even  gently  move  the  legs.  The  breathing  if 
closely  observed  is  seen  to  be  mainly  costal  in  type  and  extremely 
shallow.  The  distress  caused  makes  abdominal  palpation  almost 
impossible.  The  constant  rigidity  encountered  is  quite  characteristic. 
The  urine  is  almost  entirely  suppressed.  Pallor  soon  becomes  marked, 
and  death  usually  results  in  two  or  three  days. 

In  Early  Life. — A  similar  train  of  symptoms  occurs  in  the  early 
years  of  life  in  peritonitis  resulting  from  disease  processes  in  other 
parts  of  the  body  as  appendicitis,  intussusception,  perforation,  trau- 
matism, strangulated  hernias,  lung  involvement,  or  following  the  acute 
infectious  diseases.  Besides  the  streptococcus,  we  have  the  pneumo- 
coccus,  gonococcus,  colon  bacillus,  or  the  ordinary  pus  organisms  as 
etiological  factors.  Pneumococcic  and  gonorrheal  peritonitis  are 
almost  distinctively  diseases  of  childhood. 

The  diagnosis  is  likely  to  be  obscured  by  the  underlying  affection. 
The  medical  attendant  is  likely  to  center  his  attention  on  the  primary 
disease  and  is  not  attracted  by  the  insidious  train  of  symptoms 
in  the  abdomen.  Invasion  of  the  peritoneum  is  evidenced  by  sudden 
high  increase  of  temperature,  or  a  subnormal  temperature  with  signs 
of  collapse,  extreme  pallor,  feeble  rapid  pulse,  120  to  180,  and  cold  ex- 
tremities. The  eyes  are  fixed  and  sunken,  nausea  and  finally  bile- 
tinged  vomiting  may  follow.  Any  attempt  to  give  medication  or  food 
by  mouth  is  apt  to  be  followed  by  vomiting.  Constipation  is  the 
rule.  The  postural  picture  is  the  same  as  that  just  described 
for  the  new-born,  except  that  a  tympanitic  condition  is  more  apt 
to  occur  and  the  young  child  may  feebly  attempt  to  ward  off  any 
attempts  at  palpation  of  the  abdomen.     The  pain  may  be  referred 


558  DISEASES  OF  CHILDREN. 

to  the  navel  or  localized  in  the  iliac  fossa.  The  leukocytes  are 
moderately  increased. 

Peritonitis  of  gonorrheal  origin  should  be  suspected  where  such 
a  train  of  symptoms  in  a  female  child  are  accompanied  by  a  specific 
vulvovaginitis. 

Pneumococcic  peritonitis  may  result  from  any  pulmonary  disease, 
and  especially  from  an  empyemic  process.  It  occurs  here  probably 
by  direct  infection  through  the  lymphatics  of  the  diaphragm.  Hema- 
togenous infection  seems  to  be  the  usual  mode,  since  pneumococcic  men- 
ingitis and  abscess  formations  are  not  unknown.  Since  the  exudation 
of  pus  is  in  this  variety  considerable  in  amount,  the  diagnosis  is  more 
readily  made  by  the  finding  of  accumulated  fluid  in  the  lower  segment 
of  the  abdomen.  If  recognized  early  and  proper  measures  of  rest  and 
posture  are  instituted,  encapsulation  is  apt  to  occur,  and  the  prognosis 
is  correspondingly  improved.  Paroxysmal  pains,  chills,  vomiting, 
severe  diarrhea,  and  abdominal  distention  are  noted  in  the  early  days  of 
the  disease.  On  palpation,  there  may  be  fluctuation,  corroborated  by 
dullness  on  percussion.  Pneumococcic  infection  of  the  peritoneum, 
though  a  dangerous  disease,  is  not  necessarily  fatal,  as  the  pus  may 
discharge  through  the  umbilicus.  If,  however,  surgical  measures  are 
not  instituted  at  the  beginning,  rapid  emaciation  and  prostration 
usually  take  place.  Diffuse  suppurative  peritonitis  may  then  result, 
and  a  serious  prognosis  is  inevitable.  The  diagnosis  as  to  the  exact 
form  can  only  be  made  by  examination  of  the  pus  which  will  show 
the  presence   of  the   diplococcus   pneumoniae. 

Diagnosis. — The  diagnosis  in  older  children  with  a  well-marked 
train  of  symptoms  is  not  so  difficult.  In  infancy  it  is  often  extremely 
puzzling  and  can  often  be  made  only  by  a  process  of  exclusion.  The 
symptom  of  pain  cannot  always  be  depended  upon,  as  it  is  often  rela- 
tively less  than  in  adult  life. 

From  intestinal  obstruction  it  is  not  always  easy  to  differentiate 
peritonitis,  but  the  lesser  amount  of  abdominal  tenderness,  absence 
of  fecal  vomiting,  and  the  passage  of  some  gas  or  feces  may  be  of  as- 
sistance. It  should  not  be  forgotten  that  these  conditions  may  be 
combined. 

Diaphragmatic  pleurisy,  or  even  pneumonia,  when  the  pain  is 
referred  to  the  abdomen  may  occasion  a  mistake,  if  a  complete  physi- 
cal examination  is  not  made. 

Prognosis. — In  infancy  it  is  invariably  bad.  In  children  peri- 
tonitis must  always  be  regarded  as  a  grave  affection,  although 
the  encapsulated  forms  offer  some  little  hope.  If  a  perforation  has 
taken  place  or  if  the  process  is  general  a  fatal  issue  is  to  be  expected. 


THE  COMMONER  SURGICAL  DISEASES. 


559 


The  gonorrheal  variety,  especially  in  older  children,  has  a  better 
prognosis. 

Treatment. — An  early  diagnosis  will  be  of  value  to  the  patient  if 
prompt  measures  are  taken  to  insure  bodily  and  intestinal  rest.  If 
the  case  is  seen  very  early,  calomel  or  a  saline  may  be  given,  before 
the  application  of  an  ice-coil.  Paregoric  for  young  children  and 
codein  h3'podermatically  for  older  cases  will  be  required  to  alleviate 
the  pain  and  to  inhibit  peristalsis.  No  attempt  should  be  made  to 
feed  the  patient.  Pieces  of  ice  or  sips  of  ice-water  to  which  brandy 
has  been  added  are  grateful  and  often  allay  vomiting.  Hypodermo- 
clysis  and  stimulants  may  be  required  for  the  pulse. 

The  surgeon  should  be  consulted  as  early  as  possible  and  decide 
as  to  the  feasibility  of  operative  interference. 

Ascites. 

By  ascites  is  meant  the  condition  produced  by  an  effusion  of 
serum  into  the  peritoneal  cavity.     It  may  occur  as  a  secondary  condi- 
tion in  peritonitis  in  any  of  its  varieties,  in  chronic   nephritis  and 
in  certain  blood  diseases.     Obstructions  to 
the  portal  circulation,  and  chronic  diseases 
of  the  heart  and  lungs  may  also  produce 
ascites. 

Diagnosis. — The  physical  signs  differ 
in  nowise  from  those  obtained  in  the  adult, 
and  therefore  may  be  omitted  here. 

Chylous  Ascites. — The  diagnosis  of 
this  rare  form  is  made  only  after  aspira- 
tion. Several  cases  have  lately  been  re- 
ported. Its  causation  is  unknown,  but  is 
attributed  to  some  obstruction  or  disease 
of  the  thoracic  duct.  The  ascitic  fluid  is 
milky  white  in  color  and  usually  contains 
fat  globules  in  a  fine  emulsion.  Leuko- 
cytes and  a  few  red  blood-cells  may  be 
found. 

Treatment. — Withdrawal  of  the  fluid  for  the  relief  of  pressure 
symptoms  may  be  necessary  in  advanced  cases,  otherwise  the  treat- 
ment resolves  itself  into  measures  directed  to  the  primary  condition. 

Ischiorectal  Abscess. 

These  abscesses  are  more  commonly  observed  in  children  of  poor 
nutrition   who   have   been   reared   under   unhygienic   circumstances. 


Fig.  UU. — Characteristic  t>hape 
of  belly  in  ascites.     {Cabot.) 


560  .  DISEASES  OF  CHILDREN. 

Through  the  lymphatic  channels  of  the  rectum,  the  perirectal  lymph 
nodes  become  infected  and  form  an  abscess.  The  diagnosis  is  made 
on  inspection  or  by  rectal  examination. 

Treatment. — Free  incision,  cleansing  with  antiseptic  solutions, 
such  as  the  peroxid  of  hydrogen  and  stimulation  with  a  2  per  cent, 
silver  nitrate  solution,  or  packings  saturated  with  balsam  of  peru  and 
castor  oil,  one  to  ten,  will  effect  a  cure.  In  tuberculous  children  these 
abscesses  may  be  exceedingly  intractable  and  do  not  tend  to  heal  until 
the  general  nutrition  is  improved. 

Rectal  Polypus. 

The  growths  are  commonly  found  low  down  in  the  rectum  and 
attached  by  a  pedicle.  Rarely  are  they  multiple  and  sessile.  On 
examination  they  are  found  to  be  adenomatous  or  fibromatous  in 
structure.     They  vary  in  size,  but  rarely  are  larger  thari  a  hazel  nut. 

Symptomatology. — The  case  is  usually  brought  to  the  attention 
of  the  physician  because  of  intermittent  hemorrhages  which  may  or 
may  not  be  accompanied  with  tenesmus.  Sometimes  only  the  fecal 
masses  are  blood-streaked.  If  the  straining  is  persistent  prolapse  of 
the  rectum  may  result.  Rectal  examination  is  indicated  with  the 
above  train  of  symptoms  and  the  source  of  bleeding  will  then  be  found. 

Treatment. — The  removal  of  the  pedunculated  tumors  is  easily 
accomplished  by  twisting  the  pedicle  or  passing  a  ligature  about  it 
before  cutting  it.  If  it  cannot  be  withdrawn  the  use  of  an  anesthetic 
and  a  speculum  will  be  required  so  that  bleeding  from  the  stump  may 
be  arrested. 

Fissure  of  the  Anus. 

This  may  occur  following  the  passage  of  a  hard  constipated 
movement.  It  is  also  seen  in  children  suffering  from  marasmus, 
syphilis,  and  eczema.  Occasionally  a  fissure  is  produced  by  undue 
dilatation  of  the  sphincter  by  injections,  suppositories  or  rectal  ex- 
aminations. Pain,  some  bleeding,  and  tenesmus  are  the  signs  which 
should  lead  to  a  careful  inspection  of  the  anal  region. 

Treatment. — The  buttocks  should  be  separated  as  widely  as  pos- 
sible and  the  fissures  touched  daily  with  a  solution  of  silver  nitrate, 
dram  one  to  the  ounce.  If  constipation  is  present  laxatives  or  enemas 
with  careful  oversight  of  the  diet  will  promote  healing.  In  intractable 
cases  the  rectum  should  be  gently  dilated,  a  feat  which  is  easily  ac- 
complished in  children  by  the  successive  introduction  of  well-greased 
fingers  beginning  with  the  smallest.  This  procedure  should  cause 
little  or  no  pain,  and  generally  effects  a  cure. 


THE  COMMONER  SURGICAL  DISEASES.  561 

Prolapse  of  the  Anus  and  Rectum. 

Prolapse  of  the  rectum  is  more  commonly  observed  in  children  of 
the  second  and  third  years  of  life.  The  protrusion  may  be  partial, 
being  onh'  a  simple  eversion  of  the  mucous  membrane,  or  complete,  in 
which  all  the  layers  of  the  rectal  wall  protrude  outside  of  the  sphincter, 
sometimes  for  one  or  two  inches. 

Etiology. — The  causes  provoking  this  condition  are  those  accom- 
panied by  much  tenesmus,  such  as  colitis,  straining  in  chronic  consti- 
pation or  diarrhea,  or  with  calculi.  Rectal  polypi  will  often  lead  to 
a  prolapse.     A  neglected  cause  is  the  use  of  stooling  chambers  too 


Fig.  1(55. — Adhesive  plaster  dressing  for  prolapse  of  the  rectum. 

large  to  give  proper  support  to  the  buttocks.  Anemic  and  badly 
nourished  children  are  particularly  prone  to  this  affection,  as  in  them 
the  pelvic  musculature  is  incompetent. 

Symptomatology. — The  protrusion  of  a  dark  red  cone-shaped  mass 
covered  by  transverse  folds  of  mucus  membrane,  and  with  a  rounded 
opening  at  the  apex  of  the  tumor  is  diagnostic.  In  some  cases  blood- 
streaked  mucus  soils  the  clothes.  The  mass  can  usually  be  readily 
replaced,  but  the  protrusion  will  be  apt  to  recur  after  straining  or 
coughing  or  with  the  next  defecation  unless  preventive  measures 
are  taken. 

Diagnosis. — Although  the  diagnosis  is  generally  easily  made, 
one  of  us  has  seen  a  mistake  made  in  a  case  of  intussusception  in  an 
infant  in  whom  the  invaginated  gut  protruded  from  the  rectum. 

Treatment. — This  consists  in  replacing  the  tumor  and  retaining 

it.     A  piece  of  gauze  covered  with  vaselin  is  placed  over  the  tumor,  and 

by  gentle  pressure  exerted  over  the  entire  mass  the  prolapsed  tissues 

will  slip  back  into  place.     If  the  reduction  has  been  delayed  too  long 

36 


562 


DISEASES  OF  CHILDREN. 


it  may  be  necessary  to  apply  ice  or  ice-cold  cloths  for  a  short  period 

and  then  to  repeat  the  above  manipulation. 

Two  wide  bands  of  adhesive  plaster  applied  over  the  buttocks, 

above  and  below  the  anus,  so  as  to  exert  firm  pressure  and  give  added 

support  to  the  pelvic  attachments,  will  retain  the  prolapse.  Local  con- 
ditions, such  as  constipation,  colitis, 
and  polypi,  should  be  remedied  and 
conditions  of  malnutrition  cor- 
rected before  a  hope  of  permanent 
cure  can  be  entertained. 

The  child  must  lie  on  a  bed- 
pan during  defecation  and  the 
movement  should  be  induced  by 
a  mild  enema  of  oil  or  glycerin. 
He  should  be  taught  to  avoid 
excessive  abdominal  pressure. 
Local  applications  of  astringents, 
such  as  the  fluid  extract  of  kra- 
meria  or  tannic  acid  ointment,  are 
helpful.  The  diet  should  be  so 
regulated  during  the  cure  that  the 
movements  passed  will  be  soft  and 
unformed.  Mild  laxatives  as  cas- 
cara  or  the  milk  of  magnesia  may 
be  necessary. 

In  exceptionally  severe  or  ne- 
glected cases,  the  prolapsing  mu- 
cous membrane  must  be  linearly 
cauterized  by  the  thermocautery  to 
produce  cicatrix,  or  a  radical  oper- 
ation may  be  necessary. 


Fig 


Kitt. — Sarcoma  of  the  lower 
abdomen. 


Malignant  Tumors  in  Children. 

While  almost  any  form  of  benign  or  malignant  growth  may  occur 
in  early  life,  it  may  be  said  that  carcinoma  is  quite  rare,  while  sarcoma 
is  much  more  frequent.  When  this  form  occurs  in  children  it  is 
much  more  malignant  than  in  adults. 

Three  types  are  known,  the  round  cell,  spindle  cell  and  giant 
cell  varieties,  the  first  being  the  most  malignant. 

Nevi  sometimes  become  sarcomatous,  but  the  bones,  kidney,  testes, 
and  epidermal  tissues  are  more  frequently  involved.  The  ends  of 
the  long  bones  showing  a  special  predilection. 


THE  COMMONER  SURGICAL  DISEASES. 


563 


I  j^Sarcoma  of  the  face  often  causes  confusion  in  diagnosis.  Sarcoma 
of  the  kidney  which  is  often  congenital  may  attain  an  immense  size. 
Their  growth  is  exceedingly  rapid  and  they  are  never  bilateral.  (See 
p.  466). 


Fig.  167. — Osteo-sarcoma  of  the  temporal  bone. 


Fio.  168. — Sarcoma  of  the  face. 

Diagnosis. — The  shape  and  size  of  the  tumor  is  determined  by  its 
site  and  the  tissues  involved.  The  tumors  are  a'  first  freely  movable 
if  located  in  soft  tissues;  they  are  seldom  hard  and  firm;  on  the  con- 


564  DISEASES  OF  CHILDREN. 

trary,  they  may  even  feel  fluctuant.  Particularly  suggestive  are  the 
superficial  veins,  usually  dilated,  which  are  found  over  these  tumors. 
The  skin  covering  them  may  be  somewhat  dusky  or  bluish  in  color. 

Metastases  occur  by  way  of  the  blood  stream,  consequently  ad- 
jacent lymphatic  glands  are  not  involved. 

Treatment. — Sarcoma  is  of  relatively  rapid  growth  and  ex- 
tension and  this  fact  makes  an  early  diagnosis  essential,  as  complete 
removal  is  the  only  treatment. 

Coley's  fluid  which  contains  the  toxins  of  streptococcus,  ery- 
sipelatosus  and  bacillus  prodigiosus  can  be  tried  in  inoperable  cases 
with  the  hope  of  arresting  the  growth.  It  is  administered  hypoder- 
matically  the  injection  being  made  into  the  periphery  of  the  growth. 
Begin  with  injections  of  one  minum,  and  as  tolerance  is  produced  the 
dose  may  be  increased  to  five  minims  twice  a  day. 

In  certain  situations  as  on  the  face,  considerable  pain  is  experi- 
enced unless  fairly  powerful  analgesics  are  given. 


SECTION  XVI. 
DISEASES  OF  THE  EAR  AND  EYE. 


CHAPTER  XLII. 
DISEASES  OF  THE  EAR. 

General  Considerations. 

Familiarity  with  the  anatomy  of  the  organs  and  structures  of 
hearing,  at  least  in  a  general  way,  is  incumbent  upon  those  whose  prac- 
tice is  among  infants  and  children. 

At  birth  the  external  bony  canal  has  not  developed  and  there  is 
present  only  a  cartilaginous  canal.  The  walls  of  the  soft  meatus 
may  in  infants  be  found  almost  in  contact  so  that  the  tympanic  mem- 
brane is  examined  with  difficulty  unless  these  are  separated.  In 
structure  the  walls  of  the  meatus  are  thicker  than  in  the  adult.  The 
vault  of  the  tympanum  is  disproportionately  large  and  may  have  an  in- 
complete tegmen.  The  Eustachian  tube  is  shorter,  horizontal,  and 
relatively  wider,  the  pharyngeal  outlet  being  on  a  line  below  the  hard 
palate.  The  mastoid  process  is  entirely  undeveloped  at  birth,  and  it 
is  not  until  puberty  that  it  assumes  the  adult  characteristics.  The 
antrum,  however,  is  developed,  surrounded  by  thin  bony  walls.  The 
close  relationship  of  the  sutures  and  the  lateral  sinuses  to  these  struc- 
tures accounts,  in  greater  part,  for  the  frequency  of  intracranial  com- 
plications in  early  life. 

Otoscopy. 

For  this  purpose  a  good  light  and  a  properly  shaped  speculum 
(see  Fig.  169)  is  necessary.  The  child's  arms  should  be  fastened  to  its 
side  by  wrapping  in  a  large  sheet  or  towel;  the  attendant  holds  the 
child  with  one  arm  thrown  about  the  chest  and  with  the  other  on  top 
of  the  head  keeps  the  ear  in  the  right  direction.  By  drawing  the  auricle 
downward  and  backward  a  better  view  can  be  obtained.  Accumula- 
tions of  wax  or  exfoliations  of  the  drum  membrane  must  first  be  re- 
moved by  the  use  of  a  fine  cotton-tipped  applicator  before  a  good  view 
of  the  drum  can  be  had  (McKernon). 

565 


566 


DISEASES  OF  CHILDREN. 


If  the  ears  of  normal  children  are  first  examined  the  method  and 
a  working  knowledge  of  the  normal  appearance  will  soon  be  obtained 
and  otoscopy  will  then  be  more  frequently  made  a  part  of  the  routine 
examination,  and  aural  complications  will  go  unrecognized  less  fre- 
quently, and  more  serious  complications,  such  as  mastoid  involvement 
and  deaf-moitism,  prevented.  The  descriptions  in  this  section  are  for 
diagnostic  purposes  and  the  reader  is  referred  to  books  on  this  special 
subject  for  details  of  treatment. 


Fig.  169. — Properly  shaped  ear-speculum. 


Otitis. 

This  is  very  common  in  early  life,  occurring  almost  always  second- 
arily to  the  acute  exanthemata,  gastroenteritis,  influenza,  adenoid 
vegetations,  and  chronic  rhinitis.  Less  commonly  it  may  follow  such 
diseases  as  typhoid  infection,  diphtheria,  acute  follicular  tonsillitis, 
and  cerebrospinal  meningitis.  It  may  also  be  induced  by  improper 
methods  of  nasal  irrigation  or  by  violently  blowing  the  nose;  the 
bacteria  in  the  nasopharynx  being  forced  into  the  Eustachian  tube. 

According  to  Liebman,  the  streptococcus  is  most  frequently  found 
(52  per  cent.),  streptococcus  mucosus  next  in  frequency  (8  per  cent.), 
then  the  pneumococcus  (6  y\  per  cent.). 

Symptomatology. — Unfortunately,  in  many  instances  otitis  occurs 
during  the  course  of  an  illness,  as,  for  example,  in  measles,  and  unless 


DISEASES  OF  THE  EAR.  567 

daily  otoscopic  examinations  are  made,  the  first  intimation  of  the  proc- 
ess is  a  discharge  from  the  external  ear.  If  after  the  acute  symptoms 
of  the  primary  disease  have  subsided  a  sudden  and  rather  constant 
elevation  of  temperature,  with  and  frequently  without  earache,  occurs, 
otitis  should  be  suspected.  In  some  cases  rupture  takes  place  even 
without  elevation  of  temperature.  When  in  infants  thera  is  restless 
sleep  with  sudden  unexplainable  outcries,  pulling  at  the  ear,  with 
pyrexia  higher  at  night,  inflammation  within  the  ear  should  certainly 
be  thought  of.  Older  children  who  are  able  to  localize  and  speak  of 
their  pain  describe  it  as  "stinging"  in  character.  The  pain  comes 
on  at  intervals  and  is  worse  toward  evening  and  during  the  night. 
Otoscopic  examination  in  these  cases  will  disclose  a  much  reddened, 
swollen,  or  bulging  membrane.  If  the  process  has  not  advanced  to 
the  point  of  actual  suppuration  there  may  only  be  found  a  crescentic 
area  above  Shrapnell's  membrane  with  absence  of  the  normal  shining 
appearance  of  the  lower  half. 

If  the  perforation  has  occurred,  the  opening  is  usually  seen  in  the 
posterior  and  lower  quadrant.  The  discharge  may  be  serous,  sero- 
purulent,  or  purulent  in  character.  Chronic  otitis  media,  sinus  throm- 
bosis, and  meningitis  sometimes  follow.  In  most  of  the  cases,  how- 
ever, following  spontaneous  rupture  or  incision  of  the  membrane  the 
discharge  after  a  time  ceases,  healing  takes  place  and  restitution  to 
normal  occurs,   often  with  little  or  no  disturbance  to  the  hearing. 

Treatment.  Prophylactic. — Daily  examination  of  the  tympanum 
in  the  course  of  the  acute  infectious  diseases,  the  removal  of  adenoid 
growths  and  hypertrophied  tonsils,  and  the  inculcation  of  habits  of 
cleanliness,  such  as  the  nasopharyngeal  toilet  (see  p.  71),  will  do 
much  to  prevent  the  involvement  of  the  ear. 

General. — Early  incision  of  the  drum  membrane  should  be 
practised  in  the  acute  cases  if  the  condition  of  the  membrane  warrants. 
Hot  irrigations  of  saline  solution  at  110°  F.  with  a  fountain  bag  held 
two  feet  above  the  ear,  give  considerable  relief,  and  in  the  milder  cases 
the  symptoms  may  entirely  subside  under  this  form  of  treatment. 
Chronic  conditions  require  copious  irrigations  with  a  warm  solution 
of  (1-10,000)  of  bichlorid  of  mercury  several  times  a  day.  It  is  best 
to  refer  these  cases  to  the  specialist  for  more  radical  treatment  if  they 
do  not  show  improvement  after  a  few  weeks. 

Mastoiditis. 

This  most  frequently  results  as  a  complication  of  acute  or  chronic 
middle-ear  suppuration  and  the  same  etiological  factors  as  given  under 
the  article  on  Otitis  concern  us  here.     The  anatomical  structures  as 


568  DISEASES  OF  CHILDREN. 

outlined  in  the  general  consideration  and  the  greater  tendency 
toward  necrosis  of  bone  in  early  life  favor  the  involvement  of  the 
mastoid  process. 

Symptomatology. — The  symptoms  appear  after  a  variable  time 
during  the  convalescence  following  an  artificial  or  spontaneous  rupture 
of  the  drum.  A  sudden  or  gradual  pyrexia  may  be  the  initial  symptom. 
This,  as  a  rule,  is  not  high,  but  continues  several  days,  reaching  its 
highest  point  in  the  evening.  Otoscopy,  if  there  has  been  a  previous 
perforation,  may  show  a  decrease  in  the  amount  of  discharge,  but  the 
pus  may  show  that  some  retention  in  the  deeper  structures  has  taken 
place  by  appearing  in  drops  after  cleaning  the  canal.  Sometimes 
there  is  seen  prolapse  and  bulging  of  the  superior  and  posterior  por- 
tion of  the  canal  wall.  Restlessness  with  frequent  periods  of  crying, 
especially  at  night,  is  present  in  most  of  the  cases.  Occasionally  the 
temperature  reaches  104°  or  105°  F.  in  the  evening,  and  the  lymph- 
glands  in  the  neighborhood  are  swollen.  The  tissues  over  the  mastoid 
may  become  edematous  and  the  auricle  is  pushed  out  from  the  scalp. 
In  unrecognized  cases  a  perimastoid  collection  of  pus  takes  place, 
especially  in  infants,  and  pressure  over  this  tumefaction  causes  a  dis- 
charge of  the  pus  which  has  collected  in  the  external  canal.  Meningeal 
symptoms  may  appear  or  in  neglected  cases  the  cerebral  symptoms 
may  predominate  and  obscure  the  diagnosis. 

Treatment. — An  early  diagnosis  is  imperative  in  mastoiditis, 
for  it  is  only  by  the  radical  operation  which  drains  the  middle  ear  that 
the  mortality  in  this  serious  disease  may  be  lowered  or  more  serious 
complications,  as  infection  of  the  jugular  bulb,  avoided. 

Infective  Cerebral  Sinus  Thrombosis. 
(Jugular  Bulb  Infection.) 

The  most  frequent  cause  of  local  infection  of  the  cerebral  sinuses 
is  suppuration  in  the  middle  ear  and  mastoid  cells.  A  general  sep- 
ticemia as  a  result  of  aural  complications  may  also  produce  sinus 
thrombosis  through  the  general  circulation.  Streptococci  are  most 
frequently  found  to  be  the  direct  cause  of  the  infection. 

Symptomatology. — The  disease  should  be  considered  if  there  is 
a  sudden  rise  of  temperature  in  a  patient  who  has  a  discharge  from 
middle-ear  disease.  This  fever  is  extremely  irregular,  septic  in  charac- 
ter, rising  often  to  105°  or  107°  F.,  with  remissions  to  the  normal  or  sub- 
normal. The  pulse  rate  is  correspondingly  high,  the  infant  is  at  first 
highly  irritable  and  restless  and  soon  becomes  apathetic  and  finally 
stuporous.     There    may    be    evidences    of    meningeal    involvement. 


DISEASES  OF  THE  EAR.  569 

Vomiting  and  convulsions  occasionally  occur.  If  the  disease  has  re- 
sulted from  the  mastoid  there  may  be  edema  in  this  region,  and  per- 
haps, a  clot  in  the  jugular  vein.  The  percentage  of  polynuclear  ele- 
ments is  high,  ranging  from  80  to  90  per  cent. 

Prognosis. — This  is  extremely  unfavorable.  A  fatal  issue  usually 
results  in  a  few  days  unless  operative  interference  is  successful. 

Treatment. — Early  diagnosis  followed  by  prompt  operative  pro- 
cedure is  the  only  recourse.     Recent  reports  show  encouraging  results. 


CHAPTER  XLIII. 
THE  COMMONER  DISEASES  OF  THE  EYE. 

Foreign  Bodies. — Foreign  bodies  are  frequently  caught  under  the 
eye-lids  of  children,  and  if  not  washed  away  by  their  own  tears  which 
are  usually  copious,  they  should  be  quickly  removed  to  prevent  in- 
flammatory changes.  The  upper  lid  can  be  everted  easily  if  the  child 
is  prone  and  correctly  held  to  prevent  interference.  The  foreign  sub- 
stance can  usually  be  easily  removed  by  a  fine  probe,  the  end  of  which 
has  been  wrapped  with  a  few  strands  of  absorbent  cotton.  Metallic 
substances  may  require  local  anesthesia,  which  is  accomplished  with 
two  drops  of  a  2  per  cent,  solution  of  cocain.  If  the  particle  is  not 
readily  removed,  the  patient  should  be  referred  to  a  properly  equipped 
ophthalmologist. 

Blepharitis. — This  is  often  observed  in  tuberculous,  anemic,  or 
poorly  nourished  children,  especially  when  they  have  a  dermatitis 
elsewhere  on  the  body.  The  secretion  as  it  dries  produces  further 
excoriations  and  aggravates  the  trouble.  Treatment  should  be  directed 
to  the  general  condition,  improving  the  nutrition  by  proper  diet,  cod- 
liver  oil  and  iron  tonics  for  the  anemia.  General  cleansing  baths  daily 
with  bicarbonate  of  soda  will  prevent  reinfection.  Locally,  the  eye- 
lids are  bathed  with  a  2  per  cent,  boric  acid  solution  until  all  the 
crusts  are  removed  and  applications  of  an  ointment  of  yellow  oxid  of 
mercury  (1-100)  are  then  made  morning  and  night  until  .a  complete 
cure  is  produced. 

Conjunctivitis — Acute. — Injuries  and  the  infectious  diseases  pro- 
duce acute  inflammations  quite  readily  in  children  and  the  mucoid  se- 
cretions are  apt  to  be  more  profuse  than  in  adults.  The  eye-lids  should 
be  gently  separated  and  the  secretions  flushed  out.  Microscopical 
examination  of  a  purulent  secretion  should  be  made  to  determine  the 
possibility  of  infection  by  the  Klebs-Loeffler  bacillus  or  thegonococcus 
of  Neisser.  A  careful  search  should  be  made  for  foreign  bodies.  If 
there  is  no  secretion,  applications  of  a  2  per  cent,  warm  boric  acid  solu- 
tion every  fifteen  minutes  may  suffice  for  a  cure.  If  the  secretion  is 
purulent,  argyrol  in  12  per  cent,  solution  may  be  ordered  or  silver 
nitrate  (1-100)  may  be  applied  by  the  physician  and  quickly  flushed 
out  with  sterile  salt  solution.  Ice-cold  applications  are  often  necessary 
and  should  be  freshly  applied  every  ten  minutes  until  the  inflammation 

570 


THE  COMMONER  DISK\SES  OF  THE  EYE.  571 

subsides.  A  drop  of  atropin  sulphate  (1-200)  may  be  necessary  two 
or  three  times  a  day  to  procure  rest  for  the  eye. 

Diphtheritic. — The  membrane  is  tenacious,  with  an  absence  of 
secretion  and  much  exudation  and  edema  in  the  eye-lids.  The  ex- 
treme rapidity  of  the  involvement  and  the  presence  of  a  possible  nasal 
diphtheria  should  excite  suspicion.  The  treatment  is  that  of  diph- 
theria elsewhere.  An  injection  of  5,000  units  of  antitoxin  should  be 
given,  and  locally  the  eye  should  be  flushed  with  boric  acid  solution 
and  kept  cold  with  ice  compresses.  Protecting  the  sound  eye  from 
infection  may  be  accomplished  by  the  use  of  a  shield  or  the  instillation 
of  a  25  per  cent,  solution  of  argyrol  every  two  hours. 

Chronic. — A  careful  examination  for  ocular  defects  should  always 
be  made  in  these  cases  and  the  child's  habits  as  to  study,  etc.,  inquired 
into.  Not  infrequently  the  condition  is  improved  by  appropriate 
general  treatment  or  a  change  from  urban  to  rural  life.  Locally, 
astringent  applications  of  zinc  sulphate  (1-250)  or  silver  nitrate 
(1-500)  may  be  made  by  the  physician  several  times  a  week  and  one  of 
the  organic  silver  salts  supplied  for  home  use,  as  argyrol  in  ten  per  cent, 
solution  one  or  two  drops,  twice  a  day.  Internally  the  syrup  of  the 
iodid  of  iron  is  often  of  assistance. 

Trachoma  {granular  conjunctivitis). — Routine  examination  of 
the  school  children  in  New  York  City  has  brought  to  light  many  cases 
of  chronic  conjunctivitis  which  are  classed  as  trachomatous.  The 
condition  occurs  in  several  children  of  a  family  and  certainly  appears 
to  be  of  a  microbic  nature.  Ordinarily  the  type  seen  is  mild  in  charac- 
ter and  is  often  classed  as  a  granular  conjunctivitis.  The  heaped-up 
granulations  and  deposits  are  plainly  seen  when  the  lids  are  pulled 
down.  The  upper  lid  should  also  be  everted  and  examined.  Mar- 
ginal ulcerations  may  occur  if  the  disease  is  allowed  to  run  its  course 

untreated. 

Treatment  is  proportionate  to  the  severity  of  the  condition. 
Prophylactic  measures  to  protect  other  children  in  the  family  and 
school  should  be  insisted  upon,  such  as  individual  towels  and  wash  cloths. 
Constant  supervision  and  treatment  will  finally  eradicate  the  con- 
dition and  lessen  the  host  of  cases  now  in  our  schools. 

Locally,  a  solution  of  zinc  sulphate  (1-250)  or  the  cupric  stick 
may  be  used  by  the  physician  several  times  a  week  on  the  granulations 
and  a  solution  of  bichlorid  of  mercury  (1-5000)  or  argyrol  10  to  20 
per  cent,  may  be  ordered  for  home  use,  one  drop  being  instilled  twice 
a  day  in  each  eye.  Severe  cases  will  require  the  expression  operation 
with  forceps  under  a  general  anesthetic. 

Chalazion.— A  chalazion  is  a  cyst  which  results  from  retention 


572  DISEASES  OF  CHILDREN. 

products  of  the  Meibomian  glands.  There  is  rarely  any  pain,  although 
discomfort  is  complained  of  by  older  children.  They  are  generally 
excised  if  they  tend  to  recur. 

Hordeolum  or  stye  is  found  on  the  margin  of  the  eye-lid  and  acts 
like  a  furuncle  on  any  other  part  of  the  body.  The  evacuation  is 
hastened  by  hot  applications  and  early  incision. 

Strabismus. — Strabismus  (squint)  may  be  either  paralytic  or  non- 
paralytic. Paralytic  squint  is  due  to  partial  or  complete  paralysis  of 
one  or  more  of  the  muscles  of  the  eye.  It  may  be  congenital,  or  it 
may  be  acquired  from  trauma  or  from  an  acute  infectious  disease, 
such  as  diphtheria  or  cerebrospinal  meningitis.  It  may  also  result 
from  photophobia,  phlyctenular  keratitis,  and  interstitial    keratitis. 

Non-paralytic  squint  in  children  is  more  common,  and  it  is  usu- 
ally convergent.  Contrary  to  a  common  belief,  children  seldom 
"grow  out "  of  it.  If  neglected,  the  squinting  eye  usually  becomes  am- 
blyopic. Neglected  "cross  eyes"  are  responsible  for  many  blind  eyes 
in  adults.  If  prescribed  sufficiently  early,  correct  glasses  accomplish 
cures  in  many  of  these  cases.  Even  young  children  can  wear  glasses 
without  danger. 

Keratitis. — This  is  usually  found  in  tuberculous  and  rachitic 
children,  secondary  to  other  ocular  and  dermal  conditions,  although 
syphilis  itself  causes  the  interstitial  or  parenchymatous  variety. 

The  condition  begins  with  congestion  and  involvement  of  the 
tissues  about  the  cornea.  There  is  photophobia,  orbicular  spasm, 
pain,  and  an  abnormal  flow  of  tears.  Later  a  haziness  is  observed  and 
vision  is  impaired.  The  superficial  lesion,  if  untreated,  soon  invades 
the  cornea,  and  ulceration  or  even  suppuration  results. 

The  phlyctenular  variety  is  most  frequent  in  early  life.  Begin- 
ning with  small  vesicles  on  the  palpebral  conjunctiva,  it  spreads  to  the 
ocular  conjunctiva  and  here  forms  characteristic  ulcerations  which 
may  leave  permanent  opacities  of  the  cornea.  Treatment  should 
be  directed  to  the  underlying  constitutional  condition.  The  inter- 
stitial form  generally  reacts  to  antisyphilitic  treatment.  Children 
poorly  nourished  or  badly  housed  must  be  removed  to  hygienic 
quarters  to  effect  a  cure.  Good  food,  fresh  air,  and  baths  add  greatly 
to  the  possibilities  of  local  treatment.  Any  fissures  in  the  angles 
should  be  treated  with  silver  nitrate  solution  (dram  one  to  the 
ounce),  followed  by  a  flushing  with  normal  saline. 

A  shade  is  to  be  worn  in  preference  to  a  dark  room  where  this  is 
practicable.  Bathing  with  hot  boric  acid  solution  three  or  four  times 
a  day  is  soothing  and  helpful.  An  ointment  of  yellow  oxid  of  mercury 
(1-100)  may  be  supplied  for  use  on  the  eye-lids  at  night  in  phlyctenular 


*  THE  COMMONER  DISEASES  OF  THE  EYE.  573 

keratitis,  and  an  ointment  of  bichlorid  of  mercury  (1-5000)  applied 
for  the  other  varieties.  A  solution  of  atropin  sulphate  (h  per  cent.) 
may  be  necessary  in  some  cases  to  give  rest  until  the  child  responds 
to  the  general  treatment. 

The  Diagnostic  Significance  of  Ocular  Affections. 

The  eye  may  so  often  be  of  assistance  in  establishing  a  diagnosis 
that  a  short  article  will  be  devoted  to  the  interpretation  of  certain 
ocular  lesions  or  manifestations. 

Every  physician  should  be  prepared  to  make  certain  simple  tests 
in  his  office  to  discover  ocular  defects  in  the  routine  examination, 
and  the  eyes  should  be  examined  even  when  the  patient  is  not  presented 
for  defective  eye-sight.  In  this  way  he  may  find  the  cause  for  back- 
wardness in  school  studies,  headache,  and  dizziness.  Of  still  greater 
importance  is  the  fact  that  recognizing  unsuspected  deficiencies  in 
visual  acuity  he  will  refer  the  child  to  an  oculist  for  more  rigid  and 
detailed  tests  and  correction  of  refractive  errors  while  the  eye  is  still 
in  the  formative  period.  All  that  is  required  for  these  tests  is  a 
Snellen's  test  card,  a  picture  card  for  children  unable  to  read,  a  candle 
placed  at  twenty  feet  and  the  multiple  rod  of  Maddox  for  testing  the 
functional  balance  of  the  ocular  muscles. 

Valk  has  shown  that  the  Americans  as  a  nation  are  found  to  be 
far-sighted  with  astigmatism.  There  is  no  doubt  that  many  of  the 
children  of  this  generation  suffer  from  overuse  of  their  eyes  because 
of  the  competition  of  school  life  and  the  multiplicity  and ■  cheapness 
of  all  forms  of  reading  matter  to  which  they  have  unrestrained  access. 

Parents  must  be  warned  of  these  conditions  and  prophylactic 
measures  advised  to  protect  the  vision  of  their  children  so  that  arti- 
ficial aid  may  not  be  required.  The  study  room  should  be  well-lighted 
and  ventilated,  with  the  desk  or  table  so  placed  that  the  light  will 
come  over  the  left  shoulder.  The  use  of  vertical  writing  is  to  be  com- 
mended. Reading  in  the  recumbent  position  or  during  convalescence 
should  be  prohibited.  Badly  printed  books  should  not  be  tolerated' 
in  these  days  of  modern  printing. 

Diagnostic  Hints. 

Ptosis  as  seen  in  children  is  usually  a  congenital  defect  as  lesions 
of  the  oculomotor  nerve  are  exceedingly  uncommon  in  childhood. 

Photophobia  is  not  uncommon  and  usually  indicates  some  in- 
flammatory affection  of  the  structures  of  the  eye,  for  example,  corneal 
ulceration.     It  does  not  usually  occur  with  conjunctival  diseases. 


574  DISEASES  OF  CHILDREN. 

Exophthalmos,  or  prominence  of  the  eye-ball,  is  sometimes  seen  in 
older  children  who  have  the  symptoms  of  goiter. 

Diplopia  indicates  parlaysis  of  any  of  the  straight  ocular  muscles, 
and  it  may  result  from  any  cause  which  will  prevent  both  eyes  being 
fixed  on  the  same  point.  The  form  varies  with  the  muscle  affected. 
It  is  sometimes  a  symptom  in  hereditary  ataxia. 

Strabismus  appearing  suddenly,  convergent  in  character  and 
accompanied  with  diplopia,  is  one  of  the  signs  of  basilar  meningitis. 
It  may  also  be  seen  in  hysteria,  but  here  is  functional  only  in  character. 

Nystagmus,  or  the  rapid  oscillations  of  the  eye-balls,  may  be  lateral, 
vertical,  or  rotary  movements.  It  usually  is  bilateral.  It  rarely 
occurs  congenitally,  and  is  then  without  serious  significance.  It  is 
observed  in  many  cerebral  diseases,  especially  those  associated  with 
congenital  defects,  in  disseminated  sclerosis,  and  in  Friedrich's  ataxia. 
Tumors  of  the  cerebellum  or  pons  may  produce  this  ocular  symptom. 
It  is  sometimes  seen  in  the  later  stages  of  hydrocephalus. 

Optic  Neuritis  (Choked  Disk),  Papillitis. — This  condition  may 
be  found  on  ophthalmoscopic  examination  and  indicates  some  form  of 
intracranial  lesion  or  affection  of  the  orbit.  Papillitis  is  seen  in 
meningitis,  particularly  of  the  tuberculous  variety;  sometimes  it  occurs 
with  tumor  and  abscess  of  the  brain. 


SECTION  XVII. 
DISEASES  OF  THE  SKIN. 


CHAPTER  XLIV. 
DISEASES  OF  THE  SKIN. 

Introduction. 

Diseases  of  the  skin  form  a  very  important  part  of  the  affections 
of  early  life.  In  infants  this  is  particularly  true  owing  to  the  hyper- 
sensitiveness  of  the  skin  which  is  suddenly  bereft  of  its  covering 
of  vernix  caseosa  at  birth  and  exposed  to  irritants  of  varying  degree 
either  from  without  or  from  within.  It  must  also  be  recollected  that 
faulty  metabolism  will  account  for  many  of  these  skin  lesions.  Young 
protoplasm  is  very  irritable,  and  hence  comparatively  slight  causes, 
may  produce  severe  lesions  of  the  skin. 

The  causative  factor  should  be  carefully  sought  after  in  each 
case  and  treatment  should  be  directed  not  alone  to  the  local  lesion,  but 
to  the  S3stemic  condition  as  well.  When  prescribing  local  treatment 
the  tenderness  and  sensitiveness  of  the  infantile  epidermis  should  not 
be  forgotten.  Better  and  more  permanent  results  are  obtained  if 
soothing  and  unirritating  drugs  are  employed  and  if  the  skin  is  pro- 
tected from  further  injury  by  prevention  of  scratching  or  further  in- 
fection. The  latter  condition  often  masks  the  nature  of  the  original 
disease,  hence  the  most  recent  lesion  must  always  be  sought  for 
diagnostic  purposes. 

A  certain  number  of  skin  diseases  are  congenital  or  are  seen  mainly 
in  infancy.  These  will  be  mentioned  first  and  then  the  commoner 
diseases  met  with  in  the  early  years  of  life,  and  finally  those  seen  for  the 
most  part  in  the  school  age. 

Ichthyosis. 

(Xerodermia). 

Ichthyosis  or  fish-scale  disease  is  regarded  as  a  congenital  skin 
affection,  mainly  transmitted  by  heredity.  It  is  characterized  by  a 
dry  scaUng  condition  of  the  skin  whose  outer  layers  are  hard,  dry,  and 
thickened  and  without  any  inflammatory  phenomena.  Several  mem- 
bers of  a  family  may  be  affected. 

575 


576 


DISEASES  OF  CHILDREN. 


Symptomatology. — The  whole  body,  as  a  rule,  may  be  covered  with  a 
scaling,  wrinkled,  papery  skin,  especially  on  the  outer  surfaces  of  the 
arms  and  legs.  In  the  flexures  of  the  joints  fissures  are  sometimes 
formed.  The  general  health  remains  unaffected.  Irritants  easily 
cause  pruritis  and  local  inflammatory  reaction. 

Diagnosis. — The  disease  is  rarely  mistaken  on  account  of  its  dis- 
tinct characteristics.  The  history  and  its  non-inflammatory  charac- 
ter would  distinguish  it  from  trophoneuroses  or  pityriasis. 

Prognosis. — It  is 'an  intractable  disease  requiring  long  and  patient 
treatment  to  affect  any  amelioration.     It  is  never  really  cured. 


Fig.  170. — Pigmented  nevus. 

Treatment. — If  the  treatment  is  begun  in  early  infancy  much 
more  can  be  accomplished  than  when  seen  later.  Baths  of  green 
soap  followed  by  inunctions  of  lanolin  or  vaselin  and  protection  of 
this  greased  surface  with  gutta  percha  tissue,  later  a  5  to  10  per  cent, 
sulphur  ointment  can  be  applied.  Life  in  the  tropical  countries  is 
favorable  to  comfort  and  possible  cure. 


Nevi. 

These  congenital  growths  may  be  vascular  or  pigmented  (moles). 
The  latter  may  also  be  hairy  or  rough  and  warty.  The  color  varies 
from  a  light  brown  to  black.  Vascular  nevi  are  due  to  local  excessive 
proliferation  of  blood-vessels  at  or  soon  after  birth.     These  disfigure- 


DISEASES    OF    THE    SKIN.  577 

ments  are  found  for  the  greater  part  in  the  corium,  and  vary  from  the 
familiar  port-wine  stains  to  pulsating  angiomata.  They  are  apt  to 
increase  in  size  soon  after  birth  and  do  not  grow  beyond  certain  limits. 

Prognosis. — Vascular  nevi  of  the  cavernous  type  may  be  danger- 
ous to  life  because  of  the  danger  of  bleeding  or  from  their  effect  on 
neighboring  structures.  Pigmentary  nevi  have  shown  metamorphic 
changes  into  later  growths  of  a  malignant  character. 

Treatment. — This  is  accomplished  by  electrolysis  or  cauterization 
acting  upon  the  corium  only.  Radiotherapy  occasionally  is  success- 
ful. Excision  offers  the  best  results;  occasionally  skin  grafting  is 
necessary  following  excision  of  large  nevi.  A  needle  may  be  heated 
to  a  cherry-red  color  and  plunged  into  the  margin  at  three  or  four 
points.  This  may  be  repeated  at  subsequent  sittings  until  the  nevus 
has  been  entirely  eradicated.  A  white  scar  remains  over  the  site. 
Ice  made  from  liquid  carbon  dioxid  is  often  suitable  for  the  removal 
of  port-wdne  stains  or  superficial  nevi. 

Dermatitis  Exfoliativa  Neonatorum. 

(Ritter's  Disease.) 

Badly  nourished  infants,  usually  nurslings,  are  affected  by  this 
disease.  It  is  quite  rare.  It  begins,  as  a  rule,  on  the  lower  half  of  the 
face  as  a  reddened  area  with  exfoliation.  This  erythema  soon  spreads 
over  the  entire  body  and  the  resulting  scaling  is  profuse.  Fissures  ap- 
pear at  the  mouth  and  anus.  Constitutional  symptoms  are  those  of 
malassimilation  or,  in  severe  cases,  those  of  sepsis.  Even  when  resti- 
tution to  the  normal  takes  place  after  patient  and  diligent  treatment, 
relapses  are  not  uncommon.     Ritter  gives  the  cause  as  a  general  sepsis. 

Course  and  Prognosis.— The  two  cases  coming  under  our  observa- 
tion in  hospital  practice  both  died.  The  mortality  is  50  per  cent. 
Occurring  as  they  do  among  the  poorer  classes,  medical  attention  is 
not  drawn  to  them  until  the  vitality  has  suffered  beyond  repair. 

Treatment. — Maintain  the  body  heat  by  the  use  of  lanolin  and 
such  clothing  as  is  recommended  for  the  premature  (see  p.  2).  Care- 
fully examine  the  breast  milk,  and  if  abnormal  a  wet-nurse  may  be 
indicated.  Strychnin  in  doses  of  gr.  ^^^  every  two  or  three  hours 
is  given  if  the  vitality  is  low. 

Pemphigus  Neonatorum. 

This  is  a  contagious  skin  disease  characterized  by  the  formation 
of  bullae  containing  a  purulent  fluid.     No  specific  microorganism  has  as 
yet  been  isolated.     The  large  vesicles  or  bullae  may  suddenly  make 
37 


578 


DISEASES  OF  CHILDREN. 


their  appearance  on  any  part  of  the  body  causing  little  or  no  systemic 
disturbance.  The  blebs  vary  from  transparent  to  grayish  forms.  The 
distended  vesicles  may  rupture,  leaving  a  crust  and  a  reddened  base, 
but  no  scar  formation  results.  The  exudate  may  infect  new  areas  or 
even  those  in  contact.  The  disease  usually  runs  a  favorable  course 
tending  to  complete  recovery  in  a  few  weeks.  They  should  be  differ- 
entiated from  the  bullous  syphilo- 
derm,  sometimes  called  syphilitic 
pemphigus,  which  occurs  mainly  on 
the  soles  of  the  feet  and  palms  of  the 
hands  with  usually  an  ulcerated  base, 
and  is  accompanied  with  other  mani- 
festations of  infantile  syphilis. 

Treatment, — Evacuate  each  bleb 
carefully  by  pricking  with  a  sterile 
needle  and  apply  zinc  stearate  for 
desiccation.  A  daily  bath  in  a  solu- 
tion of  bichlorid  of  mercury  (1-10,000) 
is  indicated  if  self-inoculation  is  evi- 
dently going  on. 


Impetigo  Contagiosa. 

This  skin  disease  usually  attacks 
the  face  at  the  corners  of  the  mouth 
and  nostrils,  although  any  portion  of 
the  body  may  exhibit  the  lesions. 
These  consist  of  grayish-yellow  sticky 
crusts  which  have  a  honey-like  dis- 
charge. They  are 'seated  upon  a  red 
base.  The  child  eagerly  picks  at  these 
crusts  and  infects  other  areas. 

Treatment. — The  general  health, 
if  deficient,  will  require  proper  feed- 
The  crusts  are  softened  by  green-soap 


Fig.  171. — Impetigo. 


ing — iron  or  cod-liver  oil 

poultices  and  removed.     The  areas  are  then  covered  with  benzoated 

lard  or  lanolin  with  bichlorid  of  mercury  gr.  i  to  the  ounce. 

Seborrhea  Capitis. 

Overactive  sebaceous  glands  produce  a  crust  of  sebum  which 
soon  becomes  dry  and  scaly.  It  commonly  occurs  upon  the  scalp 
and  forehead  in  infants,  and  is  known  by  the  laity  as  "milk  crust." 
It  is  a  dirty  yellow,  firmly  adherent  mass  lying  upon  an  uninflamed 


DISEASES    OF   THE   SKIN.  579 

surface.     It  is  more  commonly  found  in  poorly  nourished  children 
than  in  lusty  breast-fed  babies. 

Treatment. — Attention  must  be  given  to  the  general  nutritional 
requirements  together  with  local  applications  of  warm  olive  oil  or  boric 
acid  ointment  (10  per  cent.)  under  an  oil-silk  cap.  AppUcations  of  the 
ointment  are  made  twice  a  day,  until  finally  the  crust  has  softened. 
They  are  then  removed  with  a  superfatted  soap  or  a  glycerin  soap  and 
the  scalp  ^nnointed  daily  for  a  time  with  a  2  per  cent,  sulphur  ointment. 

Erythema  Multiforme. 

This  is  an  acute  inflammatory  disease,  in  which  are  variously 
produced  areas  of  erythema,  macules,  papules,  or  vesicles.  Some 
constitutional  disturbance  may  usher  in  the  attack.  This  is  usually 
mild  in  character;  there  may  be  fever  and  malaise  with  or  without 
rheumatic  pains.  The  lesions,  as  a  rule,  appear  on  the  extensor  sur- 
faces of  the  hands,  arms,  feet,  and  legs.  The  face  and  upper  chest  are 
often  involved,  although  any  part  of  the  body  may  exhibit  the  erup- 
tion. The  color  varies  from  a  light  red  at  first  to  a  deep  red  in  older 
lesions.  Only  occasionally  are  hemorrhagic  areas  seen.  Pruritus,  is 
not  a  marked  symptom.  Accompanying  the  erythema  in  children 
there  are  usually  observed  symptoms  of  intestinal  derangement, 
autointoxication,  ptomain  poisoning,  etc.,  which  have  undoubtedly 
produced  this  external  manifestation.  The  disease  is  liable  to  recur- 
rence, lasting  as  a  rule,  for  a  few  weeks  before  subsiding. 

Treatment. — This  should  be  mainly  directed  to  the  underlying 
viceral  derangement.  An  initial  purge  is  indicated  in  the  form  of 
calomel  or  castor  oil.  A  careful  history  of  the  child's  diet  will  nearly 
always  disclose  some  radical  fault  which  needs  correction.  A  specially 
arranged  dietary  should  be  provided.  The  emunctories  should  be  kept 
active.  Locally,  if  there  is  pruritus,  an  ointment  containing  resorcin 
or  acid  carbolic  may  be  applied. 

Acute  Exfoliative  Dermatitis. 

This  condition  is  of  interest  because  of  the  confusion  which  it 
may  cause  in  children  from  its  resemblance  to  scarlatinal  infection. 

Intestinal  toxemia  will  commonly  be  found  to  be  the  underlying 
cause.  Following  an  erythema  of  the  scarlatiniform  type,  in  a  few 
days  or  sometimes  hours,  there  occurs  a  profuse  exfoliation.  Con- 
stitutional symptoms  are  more  pronounced  than  in  scarlatinal  ery- 
thema. The  exfoliated  scales  of  large  and  papery  strips  are  cast  off 
(see  Fig.  8,  Plate  IX).     The  hair  and  nails  may  drop  out  before  the 


580  DISEASES  OF  CHILDREN. 

process  is  complete.  Furnuncles  and  pustules  are  sometimes  en- 
grafted on  the  dermatitis  with  involvement  of  the  neighboring 
lymphatic  glands. 

Diagnosis. — The  differential  diagnosis  in  the  erythematous  stage 
and  in  that  of  exfoliation  is  given  under  the  article  on  Scarlet  Fever 
(see  page  236). 

Treatment. — Correct  the  toxemia  by  unloading  the  intestine  and 
prescribing  a  diet  that  will  not  cause  fermentation.  Repeated 
examinations  of  the  urine  for  indican  will  assist  in  properly  meeting 
this  indication.  Fowler's  solution  with  iron  is  of  value  after  the 
dietary  error  has  been  corrected.  A  2  to  5  per  cent,  ichthyol  ointment 
is  soothing  to  the  skin.  The  cure  is  slow  and  recurrences  are  frequent. 
The  exfoliation  may  occur  two  or  three  times  a  year. 

Eczema. 

{Tetter;  Salt-rheum.) 

This  is  a  protean  disease  of  unknown  origin  assuming  an  acute, 
subacute,  or  chronic  course,  characterized  by  an  erythematous  eruption 
of  varying  intensity  which  goes  on  to  scaling  or  crusting  and  is  asso- 
ciated invariably  with  marked  pruritus. 

It  is  the  most  common  of  all  the  skin  diseases  observed  in  early 
life. 

Etiological  Factors. — Irritants  either  of  external  or  internal  origin 
or  both  are  responsible  for  the  affection.  Children  who  have  nutri- 
tional or  blood  disorders  are  particularly  susceptible.  The  usual 
pyogenic  bacteria  found  on  the  skin  are  no  doubt  responsible  in- 
directly for  many  cases.  Their  growth  is  facilitated  or  increased  by 
mechanical  or  chemical  irritants  with  which  the  child  comes  into 
contact.  The  so-called  "predisposition"  to  the  disease  is  often 
accounted  for  by  careful  investigation  for  the  cause  along  the  lines 
above  enumerated.  Parasitic  skin  diseases,  discharges  from  various 
parts  of  the  body,  badly  prepared  soaps  and  powders,  and  irritating 
underclothing  are  among  the  more  common  external  causes.  Excess- 
ive feeding,  in  general  or  in  kind,  and  constipation  are  the  prominent 
internal  causes. 

Varieties. — Depending  upon  the  degree  of  the  exudative  inflam- 
mation in  the  epithelium,  there  is  produced  an  erythematous,  papular, 
vesicular,  or  pustular  eczema. 

These  forms  either  remain  distinct  or  merge  one  into  the  other, 
somewhat  masking  the  original  type.  The  erythematous  variety  is 
characterized  by  redness  and  swelling  over  certain  areas,  especially  the 


DISEASES    OF    THE    SKIX. 


581 


face.  The  papular  type  is  known  by  the  formation  of  small  red  pap- 
ules which  tend  to  group  and  coalesce.  In  the  vesicular  phase  the 
upper  layers  of  the  epidermis  are  raised  by  the  exudative  process,  form- 
ing vesicles  or  blebs  which  tend  to  coalesce  and  exude  a  viscid  serum. 
These,  however,  are  evanescent  and  are  rarely  seen  because  they  are 
rapidly  dissolved  off,  leaving  a  wet  surface.  If  the  latter  form  becomes 
infected  by  pyogenic  skin  bacteria  or  over- 
loaded with  leukocytes  the  pustular  form 
develops. 

Sub-varieties. — When  the  discharge 
in  the  vesicular  form  dries  readily  it  forms 
crusts  (E.  crustosum).  If  the  exudation  is 
profuse  and  the  rete  is  uncovered,  the 
weeping  or  moist  form  results  (E.  madinans 
vel  rubrum).  A  squamous  variety  is 
superimposed  or  develops  from  the  crusty, 
papular,  or  vesicular  form  when  consider- 
able epidermal  infiltration  and  scaling 
appears. 

Chronic  Varieties. — These  result 
from  repeated  recurrences,  or  exacerba- 
tions, or  neglect  of  the  etiological  factors. 
The  chief  characteristic  is  the  infiltration 
into  the  upper  layer  of  the  skin. 

Symptomatology  and  Diagnosis. — All 
the  varieties  described  above  have  certain 
common  features,  namely,  redness,  itching, 
and  burning,  accompanied  by  the  forma- 
tion of  papules,  vesicles,  or  pustules.  The 
skin  being  either  dry,  moist,  infiltrated,  or 
scaling.  In  infants  the  scalp,  face,  and 
napkin  region  are  most  frequently  attacked. 

The  diagnosis  is,  as  a  rule,  not  difficult  if  the  above  description  and 
classification  is  kept  in  mind.  Erysipelas  is  distinguished  by  the 
rapidly  spreading  margin  and  high  fever.  Scabies  is  often  confounded 
with  eczema  or  the  two  are  combined.  The  distribution  and  the  itching 
which  is  worse  at  night,  the  history  of  the  other  children  or  members 
of  the  family  similarly'  affected,  or  the  burrows  and  their  contents 
themselves  can  be  depended  upon  to  establish  the  diagnosis.  Psoriasis 
is  rare  in  early  life;  it  is  never  moist,  it  is  commonly  found  upon  the 
elbows  and  knees  and  has  silvery  scales.  Syphilides  occasionally  are 
difficult  to  distinguish.     The  infiltration  is  deeper  and  greater;  they 


Fig.  172. — Chronic  eczema. 


582 


DISEASES  OF  CHILDREN. 


do  not  burn  or  itch  and  are  usually  accompanied  by  other  manifesta- 
tions. In  difficult  cases  the  Wasserman  test  may  be  employed.  Im- 
petigo contagiosa  has  discrete  vesicles  upon  slightly  reddened  skin, 
with  abrupt  margins.  They  are  contagious  and  the  child  easily 
inoculates  itself  in  different  parts  of  the  body. 

Prognosis. — This  is  variable,  depending  upon  the  underlying 
cause  and  the  time  of  instituting  treatment.  Acute  cases  are  favor- 
able but  the  chronic  varieties  are  often  intractable  and  persist  with 
exacerbations  and  recurrences  for  years. 


Fig.  173. — Child  with  eczema  fitted  with  metallic  glove  to  prevent  scratching. 


Acute  Eczema. — Treatment.  General. — The  underlying  cause 
should  be  carefully  sought  for  and  removed.  If  this  is  accomplished 
the  cure  will  be  well  under  way.  Especially  important  is  the  proper 
regulation  of  the  diet.  If  there  is  present  such  a  condition  as 
rickets,  marasmus,  or  anemia  the  diet  must  be  so  arranged 
as  to  overcome  the  nutritional  disorder.  Cod-liver  oil  is  often 
helpful.  If,  on  the  other  hand,  there  has  been  overfeeding  or  indul- 
gence in  special  articles  as  the  sugars  or  potatoes,  such  indiscretion 
must  be  stopped.  The  constipation  should  be  relieved  by  correct- 
ing the  diet   or  adding  thereto  such   articles  as  fruits,  the  drinking 


DISEASES    OF    THE    SKIN. 


583 


of  plenty  of  water  and  appropriate  massage  and  exercises.  In  in- 
fants the  milk  of  magnesia  may  be  added  to  the  milk  for  its  laxative 
effect. 

Local. — Never  allow  soap  or  water  to  be  used  on  any  eczema- 
tous  surface.  Cleansing  can  be  satisfactorily  accomplished  with  olive 
or  linseed  oil.  The  irritated  skin  must  be  treated  by  bland,  soothing 
ointments  or  powders  and  scratching  absolutely  prevented.  Rest 
for  the  inflamed  area  is  imperative. 
Scratching  is  prevented  by  the  use  of 
masks,  bandages,  or  sleeves  as  shown 
in  the  illustration  (Fig.  174). 

The  mild  cases  of  the  erythem- 
atous, papular,  or  moist  types  may 
be  dusted  with  stearate  of  zinc,  car- 
bonate of  magnesia,  oxid  of  zinc,  or 
boric  acid. 

In  the  inflammatory  stages 
lotions  of  2  per  cent,  boric  acid,  cala- 
min,  or  a  1  per  cent,  solution  of 
aluminum  acetate  are  applied  as  moist 
dressings.  These  soothe  and  reduce 
the  inflammation.  Occasionally  small 
areas  of  weeping  eczema  may  be 
rapidly  improved  by  the  primary  ap- 
plication of  i  per  cent,  solution  of  the 
nitrate  of  silver.  Among  the  oint- 
ments, Lassar's  paste  (N.  F.)  has  given 
us  the  best  results.  It  is  applied 
thickly  over  the  inflamed  area  and  a 
retaining  bandage  or  mask  is  applied. 
If  thick  crusts  are  present  these  must  first  be  removed  with  applica- 
tions of  olive  oil  or  boric  acid  ointment.  The  dressings  are  removed 
daily,  the  ointment  carefully  removed  with  absorbent  cotton  dipped 
in  oil  and  the  ointment  reapplied. 

Subacute  Eczema. — If  for  any  reason  treatment  has  been  delayed 
or  has  been  unsuccessful  in  the  acute  stage  more  stimulating  applica- 
tions are  necessary.  The  amount  of  oxid  of  zinc  in  the  pasta  La.ssar 
(N.  F.)  may  be  increased,  and  small  amounts  of  tar  in  the  form 
of  tincture  picis  Uquidae  may  be  added,  or  the  following  may  be  used: 

I^.     Picis  liquid* OSS 

Sulphuris  prsecipitati oj 

Unguenti  zinci  oxidi -  ■  ■  5ij 

Misce  et  signa.— Apply  morning  and  evening. 


Fig.  174.— Eczema  mask  with  stiff 
sleeves  to  prevent  scratching. 


584  DISEASES  OF  CHILDREN. 

The  same  precautions  must  be  observed  to  prevent  scratching  or  irri- 
tation of  the  area  and  the  diet  and  bowels  regulated. 

Chronic  Eczema. — Perseverance  and  careful  watchfulness  as  to  the 
action  of  the  drugs  used  in  this  form  will  be  necessary  to  effect  a  cure. 
The  thick  crusts  must  first  be  removed  by  applications  of  oil,  boric 
or  bismuth  ointment.  Stimulating  ointments  are  then  to  be  used. 
The  majority  of  children  bear  the  ointments  well,  but  occasionally 
they  are  not  well  tolerated  and  stimulating  lotions  or  baths  must  be 
substituted.  Tar  is  added  in  greater  proportion  to  the  ointments  which 
have  been  recommended  above.  The  tincture  picis  liquidse  or  the 
liquor  carbonis  detergens  act  advantageously  by  producing  stimula- 
tion and  at  the  same  time  preventing  itching.  If  large  areas  are 
affected,  it  is  well  to  apply  the  tar  ointment  to  limited  portions  of  the 
skin  first  and  observe  its  effect.  After  it  has  produced  an  acute  reac- 
tion, the  milder  pastes  are  applied. 

Psoriasis. 

Psoriasis  among  the  skin  affections  is  quite  commonly  observed 
in  apparently  healthy  children.  It  begins  as  a  papular  affection  with 
silvery  scales  on  their  summits.  Their  growth  causes  the  commonly 
observed  irregular  patches  with  well-defined  edges,  of  a  bluish-red 
color,  somewhat  raised  above  the  surrounding  skin.  Invariably 
silvery  scales  are  found  in  these  plaques  which  can  be  readily  removed, 
leaving  a  reddish  glazed  base.  The  extensor  surfaces  of  the  extremi- 
ties are  the  favorite  seats,  next  to  the  trunk  and  scalp.  The  affection 
is  a  chronic  one  with  a  great  tendency  to  return  in  spite  of  well-directed 
treatment.  Spontaneous  cure  in  the  summer  months  is  not 
uncommon. 

Treatment. — Bulkley  emphasizes  the  dietetic  treatment  and  as 
the  youthful  patient  is  apt  to  be  indiscreet,  this  should  be  the  first 
consideration.  A  vegetarian  diet  may  be  appropriate  for  the  child 
with  a  rheumatic  history,  although  obviously  unfitted  for  an  anemic 
child  below  weight.  Outdoor  life  at  the  seashore  with  sea-bathing 
is  productive  of  much  good.  As  soon  as  the  lesion  appears  an  applica- 
tion of  green  soap  and  a  full  bath  are  ordered  to  remove  the  super- 
ficial scales.  A  crysarobin  ointment  is  applied  to  a  small  area  in 
the  strength  of  5  to  10  grains  to  the  ounce  (except  to  the  face)  twice 
a  day  until  the  skin  is  clean.  Latterly  X-ray  treatment  has  produced 
rapid  results.  Warning  should  always  be  given  as  to  its  liability  to 
return  and  the  importance  of  renewing  the  treatment  early. 


DISEASES    OF   THE   SKIX.  585 

Miliaria. 

{Prickly  Heat;  Strophulus.) 

Miliaria  is  an  affection  developing  at  the  sudariporous  glands, 
usually  during  the  summer  months.  It  consists  of  numberless  minute 
reddish  papules  and  vesicles  which  appear  with  or  after  an  unusual 
amount  of  perspiration.  It  is  accompanied  by  itching  and  burning. 
After  a  few  days  to  a  week  it  subsides,  although  fresh  outbreaks  are 
likely  if  weather  conditions  are  favorable.  Evidences  of  scratching 
are  often  seen  in  children  in  connection  with  miUaria. 

Treatment. — A  4  per  cent,  solution  of  boric  acid  is  soothing,  or 
with  infants  bran  baths  may  be  used.  Frequent  bathing  and  light 
clothing  are  prophylactic  measures  with  children  in  the  summer 
months.  Removal  to  the  seashore  and  sea-bathing  produce  rapid 
amelioration  and  cure. 

Urticaria. 

(Nettle-rash;  Hives.) 

Urticaria  consists  of  large  wheals  made  up  of  a  localized  area  of 
edema  in  the  papillary  layer  of  the  skin.  Their  centers  are  pale,  while 
the  margins  are  reddened.  These  wheals  are  distinctly  felt  by  the 
hand  and  cause  intense  itching,  especially  at  night.  In  the  majority 
of  cases  urticaria  results  reflexly  from  intestinal  causes.  External 
irritants,  such  as  the  stinging  nettle  (hence  one  of  its  names),  insect 
bites,  etc.,  may  bring  on  a  typical  attack.  Certain  fruits,  as  strawberries, 
and  certain  kinds  of  drinking  water  produce  urticaria  in  the  predis- 
posed. A  small  papular  urticaria,  consisting  of  minute  papules,  the 
tops  of  which  are  soon  scratched  off,  causing  a  drop  of  serum  or  blood 
to  exude,  may  often  be  seen  in  early  life.  This  form  may  persist  for 
months  and,  if  neglected,  will  eventually  result  in  a  form  of  papular 
eczema.  This  variety  is  in  all  cases  the  result  of  a  prolonged  faulty 
diet.     Strophulus  is  a  name  sometimes  given  to  this  condition. 

Treatment. — Discover  the  offending  cause,  whether  external  or 
dietary.  Locally,  baths  containing  bicarbonate  of  soda,  salines  for 
the  bowels,  and  local  applications  of  ointments  containing  menthol, 
camphor,  or  carbolic  acid.  Small  doses  of  salicylate  of  sodium  or 
aspirin  will  relieve  the  intestinal  fermentation  that  is  often  the  under- 
lying cause  of  urticaria. 

Funinculosis. 
This  Is  a  condition  in  which  boils  occur  over  anj'  part  of  the  body, 
but  especially  about  the  head.     They  are  due  to  an  infection  of  the 
skin  with  pyogenic  organisms.     The  staphylococcus  pyogenes  aureus 


586  DISEASES  OF  CHILDREN. 

is  the  predominating  cause.  They  differ  in  their  virulency  and 
occasionally  cause  marked  systemic  infection.  Lowered  vitality 
from  malnutrition,  improper  feeding,  previous  debilitating  diseases, 
and  skin  diseases  predispose  to  the  formation  of  furuncles. 

They  are  usually  small  in  size,  multiple,  and  tend  to  rapid  for- 
mation of  pus.  If  uncared  for,  they  rupture  and  the  pus  may  in- 
oculate other  abraded  surfaces.  The  areas  are  painful  to  the  touch, 
reddish  or  bluish-red,  and  discharge  a  yellowish,  creamy  pus.  A  case 
is  seldom  observed  in  the  very  young.  Children  with  furuncles  are 
restless,  sleep  badly,  may  have  a  low-grade  temperature,  cry  inor- 
dinately, and  lose  flesh  and  strength. 

Treatment.  Local. — A  general  bath  in  bichlorid  of  mercury 
(1-5,000)  is  first  ordered;- surround  the  furuncles  in  which  suppuration 
has  occurred  with  lanolin  and  incise  and  drain  completely,  exercising 
care  not  to  infect  neighboring  regions  with  the  pus.  Remove  local 
causes,  if  any,  as  scabies. 

General. — Improve  by  diet  and  fresh  air  the  general  tone,  pre- 
scribing strychnia,  nux  vomica,  or  the  bitter  wine  of  iron  in  the  anemic. 
The  opsonic  index  may  be  raised  by  the  injection  of  sterilized  emul- 
sions following  Wright's  method  in  cases  in  which  recurrences  are 
common  or  in  which  the  systemic  infection  is  marked. 

Angioneurotic  Edema. 

(Acute  Circumscribed  Edema.) 

This  affection  is  characterized  by  circumscribed  areas  of  edema 
which  appear  suddenly  and  have  a  tendency  to  disappear  as  sud- 
denly as  they  came.  Parents  of  children  so  attacked  are  usually 
alarmed  and  ascribe  the  edema  to  some  form  of  insect  bite.  Neurotic 
children  with  faulty  digestive  disturbances  are  especially  prone,  and 
recurrences  are  not  unusual.  Parts  of  the  face,  chest,  or  an  extremity 
may  be  involved.  The  intestinal  tract  is  sometimes  said  to  be  attacked. 
We  have  seen  the  lungs  involved,  producng  alarming  symptoms  which 
disappeared  after  a  few  hours. 

Treatment. — Correct  the  habits  and  mode  of  life  if  necessary. 
Rhubarb  and  soda  mixture  internally  and  applications  of  aluminum 
acetate  solution  (N.  F.),  externally,  promote  relief. 

Herpes  Zoster. 

(The  Shingles;  Zoster.) 
Herpes  zoster  is  a  painful  acute  inflammatory  affection  charac- 
terized by  the  production  of  a  vesicular  eruption  appearing  over  the 


DISEASES    OF    THE    SKIN. 


587 


course  of  distribution  of  the  cutaneous  nerves.  It  is  accompanied  by 
an  inflammation  of  the  peripheral  nerves  or  of  the  sensory  ganglia  of 
the  posterior  nerve  roots. 

Following  a  day  or  two  of  localized  pain,  there  appear  on  one  side 
of  the  body  a  crop  of  vesicles  having  a  reddened  inflamed  base,  which 
are  seen  to  follow  the  distribution  of  an  affected  nerve.     The  vesicles, 


Fig.  175.— Herpes  Zoster.     (Walker.) 


as  a  rule,  dry  up  without  pustulation,  unless  infected  by  unclean  chil- 
dren. Adults  suffer  more  intensely  with  this  affection  than  do  children. 
It  is  recognized  by  its  unilateral  distribution  over  a  nerve  tract  em- 
phasized by  the  symptom  of  pain. 

Treatment. — Locally,  stearate  of  zinc  as  a  dusting  powder  and  a 
protective  dressing  are  required.  Small  doses  of  phenacetin  or  codein 
may  be  required  for  the  relief  of  pain.  The  incandescent  lamp  has 
given  relief  in  some  cases,  as  have  the  X-rays. 


CHAPTER  XLV. 

PARASITIC  SKIN  DISEASES. 

Children  are  more  liable  to  this  group  of  diseases  because  of  their 
vulnerable,  tender  skin,  and  because  even  clean  children  are  apt  to 
mingle  with  their  uncared-for  schoolmates. 

Pediculosis. 

These  are  insects  readily  seen  under  a  low-power  glass.  The 
head  louse  is  from  1  to  2  mm.  in  length,  has  a  head,  thorax  and  abdo- 
men, and  a  sharp  proboscis  by  which  it  attaches  itself.  They  are  ex- 
tremely prolific,  the  female  laying  about  fifty  eggs,  and  the  young  being 
ready  to  multiply  their  kind  after  three  weeks  of  life.  The  ova  are  en- 
veloped in  a  capsule  and  are  attached  to  the  hair. 
These  are  commonly  known  as  nits.  The  parasite 
feeds  by  imbedding  its  proboscis  in  the  scalp  and 
sucking.  Thus  the  intense  itch- 
ing is  caused.  Scratching  causes 
further  irritation  and  patches  of 
eczema  may  appear.  The  post- 
cervical  glands  are  enlarged  in 
neglected  cases,  and  a  red  line  at 
the  base  of  the  hair  behind  is  often 

Pjq  I7g Pedicu-  visible  to  confirm  the  diagnosis, 

lus  capitis.    Micro-  The  nits  are  distinguishable  from 
Sholmake^)  ^'^'^^^'  dandruff  scales  by  their  position 
on  the  hair,  their  tenacity  to  it, 
and  the  ability  to  move  them  up  and  down  the  hair. 

Treatment. — Cut  the  hair  as  closely  as  possible  in  long-standing 
cases  if  no  great  objection  is  made.  Apply  a  cap  made  of  a  light 
towel  soaked  in  coal-oil  (kerosene)  or  pour  alcohol  over  the  scalp,  be- 
ginning at  the  base  with  the  head  held  over  a  basin,  the  parasites  will 
then  move  on  before  it  and  are  washed  away.  In  the  daytime  a 
10  per  cent,  boric  ointment  is  rubbed  into  the  scalp  in  aggravated  cases 
to  allay  the  irritation. 

Scabies. 

(The  Itch.) 
Scabies  is  a  disease  of  the  skin  produced  by  the  Sarcoptes  scabiei 
or  itch-mite  which  by  its  entrance  into  the  skin  produces  burrows  and 

588 


Fig.  177.— Nits  of 
pediculus  capitis. 
(After  Anderson.) 


PARASITIC  SKIN  DISEASES.  589 

an  eruption  of  vesicles,  pustules,  and  nodules.  To  these  are  added 
the  scratch-marks  produced  by  the  patient's  finger-nails.  Infants 
and  young  children  are  greatly  annoyed  by  the  irritation  and  the 
evidences  of  scratching  are  observed  early.  The  interdigital  spaces, 
the  wrists  and  flexor  surface  of  the  forearms,  the  toes  and  inner  surfaces 
of  the  thighs  are  especially  affected.  The  whole  body  may  be  invaded 
in  unrecognized  or  neglected  cases.  The  prominent  symptom,  itching, 
is  worse  when  the  patient  is  in  a  warm  bed.  If  the  child  is  predisposed 
to  eczema  this  is  almost  sure  to  supervene,  and,  in  fact,  sometimes 
masks  the  original  cause.  The  disease  is  com- 
monly seen  in  dispensary  children,  who  are 
apt  to  sleep  with  others  and  receive  meager 
bodily  attention. 

The  itch-mite  can  with  care  be  seen  by 
the  naked  eye.  The  female  is  larger  than  the 
male.  They  are  ovoid  in  shape,  covered  with 
hairs  and  have  a  pair  of  mandibles  by  which 
they  attach  themselves  to  the  skin  in  burrow- 
ing. The  female  deposits  its  eggs  and  per- 
ishes, while  the  colony  work  their  way  to  the 
outer  skin  and  start  burrows  of  their  own.        Fig.  178.— The  itch-mite 

Treatment. — The  disease  is  readily  amen- 
able to  cure  if  certain  rules  are  followed  faithfully.  Remove  all  the 
clothing  and  bedclothes  and  sterilize  them  by  boiling  or  baking  in  an 
oven.  Follow  a  vigorous  soap  and  hot-water  bath  with  the  applica- 
tion of  sulphur  ointment  drachm  one  to  the  ounce.  If  eczema  is 
present,  use  mild  detergents,  especially  in  the  case  of  infants.  Pow- 
dered sulphur  may  be  used  in  children  or  a  solution  of  styrax  in  the 
strength  of  half  an  ounce  to  the  ounce  of  lanoUn.  The  ointment 
selected  should  be  applied  to  the  whole  body  twice  a  day  and  two 
weekly  baths  taken.  If  there  is  a  superadded  eczema,  treat  the 
latter  along  the  lines  outlined  for  that  disease. 

Tinea  Tonsurans. 

{Ringworm  of  the  Scalp.) 

This  is  a  contagious  disease  produced  by  a  vegetable  parasite, 
beginning  as  a  mass  of  minute  vesicles  which  soon  aflfect  the  hair. 

The  lesion  consists  of  a  rounded  patch  showing  broken-off  hairs 
(shaven  beard  appearance)  or  a  partly  bald  area,  with  extension 
taking  place  into  the  periphery.  The  central  area  is  more  or  less 
reddened  with  a  dirty  scaly  margin. 

The  disease  is  almost  entirely  confined  to  children,  rarely  appear- 


590  DISEASES  OF  CHILDREN. 

ing  after  puberty;  children  infect  each  other  directly  or  through 
articles  of  clothing  or  toys  or  through  their  pets.  The  patches  are 
rarely  seen  by  the  physician  while  vesicles  are  present. 

The  diagnosis  must  be  made  on  the  presence  of  the  gnawed-off 
hairs  in  a  rounded,  reddened,  scaly  field  in  which  the  fungus  can  be 
found  on  the  hairs. 

Examination  for  the  Fungus. — A  loosened  diseased  hair  may  be 
placed  on  a  slide  and  soaked  in  a  10  to  20  per  cent,  potash  solution,  and 
examined  for  the  parasite  under  the  microscope  with  at  least  a  5- 
inch  lens. 

Treatment. — Ringworm  does  not  respond  quickly  to  treatment. 
If  depilation  is  first  performed,  a  better  response  to  antiparasitic 
remedies  is  obtained.  The  scalp  should  be  cleansed  for  several  days 
with  green  soap  and  water.  The  surrounding  hair  is  best  kept  short 
or  if  possible  shaved  about  the  lesion.  A  solution  of  potash  applied 
on  a  piece  of  gauze  and  rubbed  in  will  remove  any  debris  that  remains 
after  the  washings.  An  antiparasitic  ointment  is  now  daily  applied 
and  a  protective  dressing  or  cap  used.  We  have  tried  to  our 
satisfaction  applications  of  oil  of  cade  and  castor  oil,  equal  parts,  or 
betanaphthol  one-half  to  one  drachm  to  the  ounce.  Ten  per  cent, 
of  aristol  in  flexible  collodion  has  commended  itself  in  children  who  are 
in  asylums  and  apt  to  infect  others.  The  X-rays  are  highly  spoken 
of  by  dermatologists  as  a  rapid  and  permanent  means  of  cure. 

Tinea  Favosa. 

Favus  is  a  feebly  contagious  parasitic  disease,  caused  by  the 
Achorion  Schonleinii.  The  lesion  consists  of  sulphur-yellow  areas  on 
the  scalp  through  which  the  hairs  appear.  The  hair  shaft  is  broken 
off,  being  diseased  by  the  fungus.  Closely  examined,  it  is  found  that 
each  hair  is  surrounded  by  a  cup-shaped  area;  these  coalescing  produce 
a  thick  matted  cake,  dirty  yellow  in  color,  sometimes  having  a  peculiar 
characteristic  odor.  Some  pruritus  is  nearly  always  complained  of. 
When  the  crusts  are  removed  a  scarred  area  with  no  hairs  present  is 
found.  The  diagnosis  may  be  confirmed  by  an  examination  for  the  fun- 
gus under  the  microscope.  A  low  power  will  answer  (250  diameters). 
A  fragment  of  hair  passed  through  a  potash  solution  will  show  the 
thick  broad  threads.     The  spores  seen  are  of  many  shapes  and  sizes. 

Treatment. — The  treatment  takes  much  time  and  patience,  and 
at  best,  bald  areas  will  occur  at  times.  Depilation  offers  the  safest 
and  best  chance  of  cure.  This  is  performed  after  cutting  short  all 
the  hair  of  the  head,  removing  thoroughly  all  the  crusts  and  debris 
with  10  per  cent,  boric  acid  ointment.     The  hairs  are  removed  best 


PARASITIC  SKIN  DISEASES. 


591 


with  Bulkley's  adhesive,  made  up  with  burgundy  pitch  or  by  repeated 
collodion  applications.  The  hairs  are  thus  removed  en  masse.  Ten 
per  cent,  oleate  of  mercury  is  then  applied  night  and  morning  with 
frequent  soap  and  hot-water  washings.  When  new  hairs  appear  the 
microscope  should  again  be  used  to  guard  against  the  reappearance 
of  the  parasite.  The  X-ray  may  here  also  give  good  results  in  com- 
petent hands. 

Alopecia  Areata. 

(Baldiiess.) 
This  is  a  disease  of  the  hairy  scalp  producing  areas  of  baldness. 
The  affection  is  apt  to  come  on  quite  suddenly  without  any  subjective 
symptoms.  The  underlying  skin  is  white,  clean,  and  soft.  When  the 
hair  returns,  which  it  does  in  children,  it  is  soft,  downy,  and  colorless 
at  first.     Later  it  slowly  shows  some  color  and  the  hairs  themselves 


Fig.  179. — Alopecia  areata. 

become  firmer  and  of  coarser  texture.  Scharaberg  believes  there  are 
two  varieties :  the  parasitic  and  the  trophoneurotic,  thus  explaining 
the  divergence  of  opinion  as  to  the  etiology. 

After  a  variable  time,  sometimes  months,  the  hair  in  children 
returns,  although  even  in  early  life  relapses  are  seen. 

Treatment.— Locally— many  remedies  have  been  advanced  as 
serviceable.  Measures  which  will  increase  the  blood-supply  in  the 
scalp  are  helpful.  Vigorous  massage,  followed  by  applications  of 
90  per  cent,  alcohol  has  been  useful  in  our  hands.  Lately  the  high- 
frequency  current  and  the  actinic  rays  have  been  extolled  in  the  cure 
by  dermatologists. 


INDEX. 


Abdomen,  as  aid  to  diagnosis,  85 

enlarged,  85 

prominent,  85 

tumors  of,  localized,  85 
Abdominal  wall,  tumors  of,  86 
Abnormalities  in  breathing,  as  aid  to 

diagnosis,  83 
Abscess,  cerebral,  520 

ischiorectal,  559 

of  brain,  520 

of  liver,  224 

of  lung,  378 

peritonsillar,  352 

pulmonary,  378 

retropharyngeal,  352 

subphrenic,  381 
Absence  of  bones,  congenital,  541 
Acetonuria,  455 
Achondroplasia,  422 

diagnosticated  from  cretinism,  426 
Addison's  disease,  418 
Adenie,  418 
Adenitis,  acute,  419 

chronic,  420 

tuberculous,  318 
Adenoids,  350 

etiology,  350 

examination,  351 

symptomatology,  350 

treatment,  351,  352 
Administration  of  drugs,  60 

of  food  for  infants,  165 
Adolescence,  39 
Adrenals,  disorders  of,  417 

hemorrhage  into,  418 
Aerotherapy,  66 
Albuminuria,  cyclic,  454 

functional,  454 

physiologic,  454 
Alopecia  areata,  591 
Amaurotic  family  idiocy,  533 
Amygdalitis,  acute,  347 
Amyloid  liver,  223 
Anemia,  401 

pernicious,  403,  406 

secondary,  401 

simple,  401 

splenic,  406 

von  Jaksch,  405,  406 
Anemias,  table  of,  406 
treatment  of,  408 

38 


Anesthesia,  549 

chloroform,  549 

gas-ether,  550 

preparation  for,  550 
Anesthetic,  choice  of,  549 
Angina,  Vincent's,  348 
Angioneurotic  edema,  500,  586 
Animal  parasites,  211 

found  in  childhood,  211 
Ankylostomum  duodenale,  216 
Anopheles  mosquito,  305,  306 
Anterior  poliomyelitis,  292 
Antitoxin,  diphtheria,  255,  256 
Anuria,  450 
Anus,  fissure  of,  560 

imperforate,  538 

malformations  of,  538 

prolapse  of,  561 

stenosis  of,  538 
Aortic  obstruction,  392 

regurgitation,  392 
Aphtha;,  183 

Bednar's,  184 
Apoplexy,  meningeal,  during  birth,  9 
Appendicitis,  552 

abscess  formation,  554 

diagnosis,  554 

etiology,  552 

examination,  553 

pathology,  552 

prognosis,  554 

suppurative  form,  553 

symptomatology,  553 

treatment,  554 
Appendix  of  infant,  34 
Arthritides,  infectious,  303 
Arthritis,  diagnosed  from  rheumatism, 
301 

tuberculous,  305 
Arthritis  deformans,  304 
Arthrogryposis,  496,  and  see  Tetany 
Artificial  respiration,  12 
Articular  rheumatism,  acute,  299 
Ascaris  lumbricoides,  212 
Ascites,  559 

chylous,  559 
Asphyxia,  during  birth,  10,  13 

artificial  respiration  in,  12 

direct  insufflation  in,  11 

preventive  treatment  of,  11 
Aspiration  of  pleural  cavity,technic  of, 54 

593 


594 


INDEX. 


Assimilation,  infants  differ  in  power  of, 
135 

most  efficient  in  early  infancy,  135 
Asthma,  bronchial,  363 

thymic,  357 
Ataxia,  Friedreich's,  510 

hereditary,  510 
Atelectasis,  congenital,  12 
Athrepsia,  439,  and  see  Marasmus 
Atrophic  paralysis,  acute,  292 
Atrophy,  idiopathic  muscular,  512 

infantile,  439,  and  see  Marasmus 
Attitude,  typical,  of  normal  infant,  29 
Auscultation  of  infants  and  children,  47 

Babinski's  reflex,  47,  289 
Balanitis,  473 
Baldness,  591 
Barlow's  disease,  437 
Basedow's  disease,  421 
Bathing,  in  infancy,  26 
Baths,  artificial  Nauheim,  71 

bed,  68 

brine,  69 

carbonic  acid,  71 

hot,  69 

hot  air,  69 

mustard,  70 

sheet,  68 

soothing,  70 

special,  69 

sponge,  68 

warm,  69 
Bed  baths,  68 
Bednar's  aphthae,  184 
Beef  juice,  to  make,  158 
Beef-tea,  to  make,    157 
Bell's  palsy,  505 

Biliary  ducts,  inflammation  of,  222 
Birth,  injuries  during,  6 

palsies,  8 
Bladder,  calculus  in,  481 

diseases  of,  480 

ectopia  of,  540 

extrophy  of,  540 

inflammation  of,  480 

of  infant,  34 

spasm  of,  481 
Blennorrhea,  urogenital,  474 
Blepharitis,  570 
Blood,  398 

cells,  red,  399 
nucleated,  399 
number  of,  399 

corpuscles,  white,  399 

corpuscular  element  of,  398 

diseases  of,  398 

examination  of,  51 

in  urine,  453 

plates,  401 

pressure,  382 
Blue  disease,  383 
Boils,  585 


Bone,  caries  of,  334 

congenital  absence  of,  541 
fractures  of,  during  birth,  7 
injuries  to,  during  birth,  7 
swollen,  88 
tuberculosis  of,  334 
Bowels,  regularity  of,  in  infancy,  27 
Brain,  abscess  of,  520 
diseases  of,  518 
tumors  of,  521 
Branchial  cysts,  congenital,  536 

fistulse,  536 
Breasts,  preparation  of,  for  lactation, 

101 
Breast-feeding,  100,  and  see  Nursing 
importance  of,  100 
intervals  of,  101 
management  of,  101 
not  possible,  107 
preparation  for,  101 
regularity  of,  101 
scanty  supply  of  milk,  102 
Breast  milk,  examination  of,  104 
for  premature  infants,  3 
reaction  of,  105 
specific  gravity  of,  104 
pumps,  106 
secretions,  92 

composition  of,  93 
properties  of,  93 
Breathing,  abnormalities  in,  as  aid  to 
diagnosis,  83 
exercises  in,  79 

mouth,  in  nasal  obstruction,  83 
Breck  feeder  for   premature  infants,  4 
Bright's  disease,  acute,  456 
Brine  bath,  69 
Bronchial  asthma,  363 

stenosis,  84 
Bronchiectasis,  379 
Bronchitis,  acute,  359 
diagnosis,  360 
etiology,  359 
physical  signs,  359 
prognosis,  360 
symptomatology,  359 
treatment,  360 
capillary,  364 
chronic,  361 
Bronchopneumonia,  acute,  364 
aerotherapy  in,  368 
clinical  forms  of,  366 
complicating  the  infectious  dis- 
eases,367 
complications  of,  367 
course  of,  368 
diet  in,  368 

differential  diagnosis  of,  367 
hydrotherapy  in,  369 
local  applications  in,  369 
medication  in,  369 
pathology  of,  364 
physical  signs  of,  365 


INDEX. 


595 


Bronchopneumonia,  prognosis  of,  368 
symptomatology  of,  364,  366 
treatment  of.  36S 
tuberculous,  322 

Buhl's  disease,  IS 

Buttermilk,  160 


Calculi,  renal.  452 

vesical,  481 
Calmette  test  for  tuberculosis,  54,  324 
Calorie  feeding,  162 
Calx  chlorata,  as  a  disinfectant,  314 
Cancrum  oris,  187 
Cap,  ice,  68 

Capillary  bronchitis,  364 
Caput  succedaneum,  6 
Carbohydrates,  forms  of,  used  in  infant 
feeding,  112 

of  cereals,  121 
CarboHc  acid,  as  a  disinfectant,  314 
Carbonic  acid  baths,  71 
Cardiac  disorders,  functional,  393 
Caries  of  bone.  334 

of  spine,  335 
Catarrhal  fever,  acute,  273 
Central  paralysis,  during  birth,  9 
Cephalhematoma,  6 
Cereal  gruels,  percentage,  140,  142 
Cereals,  120 

properties  of,  120 

carbohydrates  of,  121 
Cerebral  palsies,  infantile,  522 

paralysis,  483 
Cerebrospinal  fever,  287 
Cestodes.  211,  214 
Chalazion,  571 
Changes  in   the  features,   as  a  sign  of 

illness,  58 
Chapin's  cream  dipper,  140 

infant  urinal,  445 
Chest,  abnormal  shape  of,  84 

as  aid  to  diagnosis,  84 
Chest-wall,  tumors  of,  84 
Chickenpox,  247 
Child,  height  of,  38 

mental  growth  of,  39 

moral  growth  of,  39 

relative  measurements  of,  32,  33 

weight  of.  38 
Childhood,  diet  during  later,  179 

growth  during,  36 

pulse  in,  45 

respirations  in,  41 
Children,  auscultation  of,  47 

mensuration  of,  48 

percussion  of,  47 

rectal  examination  of.  48 
Children's  hospitals,  diet  lists  for,  177 
Chlorid  of  lime,  as  a  disinfectant,  314 
Chlorin,  as  a  disinfectant,  313 
Chloroform  anesthesia,  549 
Chlorosis,  402,  406 


Choked  disk,  574 
Cholera  infantum,  206 
Chondrodystrophy,  fetal,  422 
Chorea,  486 

complications,  488 

course,  488  \ 

diagnosis,  488 

etiology,  486 

forms  of,  489 

pathology,  487 

prognosis,  488 

symptoms,  487 

treatment,  488 

Huntington's,  489 

insaniens,  489 

major,  489 

minor,  486 

Sydenham's,  486 
Chvostek's  symptom  in  tetany,  498 
Chylous  ascites,  559 
Circumcision,  552 
Cirrhosis  of  liver,  224 
Claw  hand,  88 
Cleft  palate,  536 
Clothing,  in  infancy,  25 
Clubbed  fingers,  88 
Club-foot,  541 
Colic,  199 

Collapse,  pulmonary,  361 
CoUes'  law,  278 
Colon,  dilatation  of,  congenital,  206 

flushing  the,  72,  73,  74 

irrigation  of  the,  72,  73,  74 
Colostrum,  93 
Compresses,  69 
Condensed  milk,  119 

mixtures,  159 
Congenital  absence  of  bones,  541 

atelectasis,  12 

branchial  cysts,  536 

dislocation  of  hip,  540 

malformations  and  deformities,  535 
Congestion  of  liver,  223 
Conjunctivitis,  acute,  570 

chronic,  571 

diphtheritic,  571 

granular,  571 

of  the  newly-born,  21 
Constipation,  208 
Convulsions,  484 

description  of  the  symptom-com- 
plex. 485 

differential  diagnosis,  486 

etiology,  485 

prognosis,  486 

treatment,  486 
Cow's  milk,  113 

composition  of,  113 

influence  of  breed  on,  113 

influence  of  breed  on  composition 
of.  113 

one.  1 13 
Coxalgia,  336 


596 


INDEX. 


Cream,  117 

centrifugal,  117 

gravity,  117 
Cream  dipper,  Chapin's,  140 
Creches,  diet  lists  for,  178 
Cresol,  as  a  disinfectant,  314 
Cretinism,  424 

differential  diagnosis,  426,  532 

etiology,  424 

prognosis,  428 

symptomatology,  425 

treatment,  429 
Croup,  252 

catarrhal,  353 

false,  353 

spasmodic,  353 

diagnosticated  from  laryngismus 
stridulus,  356 

tent,  355 
Croupous    pneumonia,    371,    and    see 

Lobar  pneumonia 
Cryptorchidism,  477 
Culex  mosquito,  305,  306 
Cyanosis,  383 

in  premature  infants,  5 
Cystitis,  480 
Cysts,  branchial,  congential,  536 

Dactylitis,  88 

syphilitic,  283 

tuberculous,  334 
Day  nurseries,  diet  lists  for,  178 
Dead-born  infant,  13 
Dead,  from  infectious  diseases,  care  of, 

315 
Death,  fetal,  13 
Deformities,  congenital,  535 

exercises   for   developing   children 
with,  78 

of  head,  6 
Delayed  growth  as  aid  to  diagnosis,  86 
Dentition,  34 

first,  34 

delayed,  35,  83 

disturbances  of,  35 
Dermatitis,  acute  exfoliative,  579 

diagnosticated  from  scarlet  fever, 
236 

exfoliativa  neonatorum,  577 
Development    of    digestive    tract,    93, 
95 

of  infant,  30 
Dextrinized  gruel,  to  make,  156 
Diabetes  insipidus,  451 

mellitus,  443 
Diacetonuria,  455 

Diagnosis,  suggestive  scheme  for,  81 
Diarrhea,  infectious,  200 

summer,  200 
Diet  during  later  childhood,  179 

during  second  year.  174 

during  third  year,  176 

from  third  to  sixth  year,  177 


Dietary  during  second  year,  174 

from  12  to  18  months,  174 

from  18  to  24  months,  175 

from  2  to  3  years,  176 

from  3  to  6  years,  177 
Diet-lists,  for  children's  hospitals,  177 

for  day  nurseries  and  creches,  178 
Digestive  organs,  comparative  anatomy 
and  physiology  of,  94 

tract,     development     of,     93,     95 
diseases  of,  189 
Dilatation  of  colon,  congenital,  206 

of  stomach,  192 
Diphtheria,  250 

antitoxin,  256 

complications,  254 

conjunctival,  254 

differential  diagnosis,  251,  252 

etiology,  250 

extubation,  261 

feeding  of  intubated  cases,  262 

general  treatment,  255 

intubation,  257 

laryngeal,  252 

local  treatment,  256 

nasal,  253 

pathology,  250 

pharyngeal,  251 

prognosis,  255 

prophylaxis,  255 

serum  treatment,  256 

symptomatology,  250 

tonsillar,  251 

tracheotomy,  262 

treatment,  255 
Diphtheritic  paralysis,  504 
Diplegia,  spastic,  522 
Diplopia,  574 

Discharges,  state  of,  as  a  sign  of  illness,58 
Disinfectants,  312 

aerial,  312 

chemical,  312 
Disinfection,  312 

of  discharges,  315 

of  room,  315 
Dislocation  of  hip,  congenital,  540 
Disseminated  sclerosis,  509 
Dosage,  60,  61 
Drugs,  administration,  60 

dosage  of,  60,  61 

elimination  of,  in  milk,  103 

frequently  used  in  pediatric  prac- 
tice, 61 
Duchenne's  paralysis,  during  birth,  8 
Ductless  glands,  diseases  of,  414 
Duke's  disease,  diagnosed  from  scarlet 

fever,  237 
Dyspepsia,  acute,  190 
Dysphagia,  false,  83 

true,  83 
Dyspnea,  expiratory,  84 

inspiratory,  83 

mixed,  84 


INDEX. 


597 


Dystrophy,  muscular,  512 

Ear,  565 

diseases  of,  565 

speculum,  565,  566 
Eclampsia     infantum,     484,     and     see 

Convulsions 
Ectopia  of  bladder,  540 
Eczema,  580 

acute,  treatment,  582 
general,  582 
local,  583 

chronic,  581 
treatment,  584 

crustosum,  581 

diagnosis,  581 

etiological  factors,  580 

erythematous,  580 

madidans,  581 

papular,  580 

prognosis,  582 

pustular,  580 

rubrum,  581 

subacute,  treatment,  583 

sub  varieties,  581 

symptomatology,  581 

varieties,  580 
Edema,  acute  circumscribed,  500,  586 

angioneurotic,  500,  586 

of  glottis,  354 
Eggs,  121 
Emphysema,  362 

acute,  362 
Empyema,  374 

exploratory  puncture,  375 

symptomatology,  374 

treatment,  376 
Encephalitis,  acute,  520 
Encephalocele,  544,  546 
Endocarditis,  acute,  385 
diagnosis,  387 
etiology,  385 
pathology,  385 
prognosis,  387 
symptomatology,  386 
treatment,  387 

malignant,  386 

septic,  386 

ulcerative,  386 
Enemata,  nutrient,  76 
Enlargement,  general,  88 
Enteralgia,  199 
Enteroclysis,  72,  73,  74 
Enterocolitis,  acute,  202 
Enuresis,  468 

treatment,  470 
Eosinophiles,  400 
Eosinophilia,  398,  401 
Epidemic  hemoglobinuria,  17 

paralysis  in  children,  297 
Epilepsy,  491 

diagnosis,  492 

etiology,  491 


Epilepsy,  grand  mal,  491 

petit  mal,  491 

prognosis,  492 

symptomatology,  491 

treatment,  492 
Epistaxis,  341 
Erb's  myotonic  reaction,  499 

paralysis,  during  birth,  8 

symptom,  in  tetany,  498 
Erysipelas,  309 

etiology,  309 

prognosis,  311 

symptomatology,  309 

treatment,  311 
Erythema  multiforme,  579 

scarlatinif  orme,  diagnosticated  from 
scarlet  fever,  235 
Erythemata,    diagnosed    from    scarlet 

fever  235 
Erythrocytes,  398,  399 
Esophagitis,  corrosive,  189 
Esophagus,  congenital  occlusion  of,  189 

inflammation  of,  see  Esophagitis 

malformations  of,  538 
Essential  paralysis  of  children,  292 
Examination  of  sick  child,  41 

blank  for,  '42 
Examinations,  special,  51 
Exanthemata,  225 

table  of,  249 
Exercise  and  fresh  air  in  infancy,  26 
Exercises,  breathing,  79 

for  developing  children   with   de- 
formities, 78 

for  increasing  respiratory  capacity, 
79 

resistant,  79 
Exophthalmic  goiter,  421 
Exophthalmos,  574 
Exploratory    puncture     in    empyema, 

374 
Expression  of  face,  82 
Extremities,  as  aid  to  diagnosis,  87 

rigidity  of,  87 

spastic,  87 
Extrophy  of  bladder,  540 
Extubation,  261  • 

Exudates,  examination  of,  53 
Evaporated  milk,  119 
Eye,     affections     of,    diagnostic    hints 
regarding,  573 
diagnostic  significance  of,  573 

diagnostic    hints    regarding    affec- 
tion of,  573 

diseases  of,  570 

foreign  bodies  in,  570 

test  for  tuberculosis,  54 


Face,  as  aid  to  diagnosis,  82 
expression  of,  82 

Facial  paralvsis,  505 
during  birth,  8 


598 


INDEX. 


Fat  in  milk,  to  decrease  amount  of,  172 
to  increase  amount  of,  172 

percentages  of,  in  different  portions 
of  milk,  138 
Fats,  forms  of,  used  in  infant  feeding,  112 
Fatty  degeneration  of  the  newly-born, 
18 

liver,  223 
Favus,  590 
Features,  changes  in,  as  a  sign  of  illness 

58 
Feeblemindedness,  529,  and  see  Idiocy 
Feeders  for  premature  infants,  4 
Feeding,  and  see  Nutrition 

calorie,  162 

directions,  outline  of,  146 

forced.  74 

in  typhoid  fever,  272 

infant,     chemical     and     biological 
standards  in,  97 

laboratory,  160 

mixed,  107 

of  intubated  cases,  262 

of  premature  infants,  3,  4 

on  large  scale,  to  make,  171 

prepared  at  feeding  station,  173 

rectal,  76 

station,  feedings  prepared  at,  173 

substitute,  see  Substitute  Feeding 

table,  suggestive,  149 
Fetal  death,  13 
Fever,  acute  catarrhal,  273 
Fingers,  clubbed,  88 

webbed,  544 
Fissure  of  anus,  560 

of  mouth,  82 

of  tongue,  82 
Fistulse,  branchial,  536 
Fontanels,  abnormal,  81 
Food,  adaptation  of,  to  infant,  152 

care  of,  in  infant  feeding,  163 

dispensaries,  170 

essential  unity  of,  91 

for  acutely  ill  infants,  156 

for  healthy  infants,  147 

for  infants,  administration  of,  165 
••for  infants  of  feeble  constitution, 
155 

for  infants  previously  badly  fed,  153 

for  infants   who  fail  to  thrive  on 
fresh  milk,  158 

of  first  nutritive  period,  91 

specialized,  92 
Foot,  club-,  541 
Forced  feeding,  74 
Foreign  bodies  in  eye,  570 

in  nose,  342 

in  respiratory  tract,  380 
Formaldehyd,  as  a  disinfectant,  312 

generators,  312 
Formalin,  as  a  disinfectant,  314 
Fourth    disease,     diagnosticated     from 
scarlet  fever,  237 


Fractures  during  birth,  7 
Fresh  air,  in  infancy,  26 

in  treatment  of  disease,  66 
Friedreich's  ataxia,  510 
Functional  cardiac  disorders,  393 
Furunculosis,  585 


Gangrene  of  lung,  378 
Gas-ether  anesthesia,  550 
Gastric  catarrh,  acute,  190 

indigestion,  acute,  190 
Gastritis,  acute,  190 

chronic,  191 
Gastroenteritis,  acute,  200 
Gastrointestinal     indigestion,    chronic, 

204 
Gavage,  74 

danger  of,  in  premature  infants,  4 
Genital  organs,  diseases  of,  472 
German  measles,  230 
Glands  of  infant,  33 
Glomerulonephritis,  acute,  456 
Glossitis,  desquamative,  181 
Glottis,  edema  of,  354 
Goiter,  exophthalmic.  421 
Gonitis  tuberculosa,  338 
Grand  mal,  491 
Graves'  disease,  421 
Growth,  delayed,  as  aid  to  diagnosis,  86 

during  childhood,  36 

mental,  of  child,  39 

moral,  of  child,  39 

of  infant,  29 
Gruels^  cereal,  percentage,  140,  142 

dextrinized,  to  make,  156 

directions  for  making,  151 
Gums,  bleeding,  83 

spongy,  83 

swollen,  83 


Hand,  abnormal,  88 

claw,  88 
Harelip,  535 
Head,  as  aid  to  diagnosis,  81 

deformity  of,  6 

injury  to,  during  birth,  6 

fontanels,  abnormal,  81 

motion  of,  abnormal,  81 

of  infant,  30 

position  of,  abnormal,  81 

shape  of,  abnormal,  81 

size  of,  abnormal,  81 

tumors  about,  81 
Headaches,  493 
Heart,  the,  382 

beats,  383 

disease,  congenital,  383 

diseases  of  the,  382 

functional  disorders  of,  393 

location  of  valves  of,  390 

palpitation  of,  394 


INDEX. 


599 


Heart,  valvular  disease  of,  389 
aortic,  392 
mitral,  391 
tricuspid,  393 
Height  of  child,  38 
Hematuria,  453 

Hematoma  of  sternocleidomastoid,  7 
Hemic  murmurs,  394 
Hemiplegia,  spastic,  522 
Hemoglobin,  estimation  of,  53 
Hemoglobinuria,  453 

epidemic,  17 
Hemophilia,  412 
Hemorrhages,  as  aid  to  diagnosis,  86 

causes  of,  general,  86 
special,  87 

from  nose,  87 

from  rectum,  87 

into  adrenals,  418 

of  new-born,  87 

of  stomach,  87 

spontaneous,  in  the  newly-born,  23 

umbilical,  15 
Henoch's  purpura,  411 
Hereditary  ataxia,  510 

course,  512 

differential  diagnosis,  511 

etiology,  510 

pathology,  510 

prognosis,  512 

symptomatology,  511 

treatment,  512 
Hernia,  550 

diagnosis,  551 

etiology,  550 

symptomatology,  550 

treatment,  551 

umbilical,  17 

Pisek's  dressing  for,  16 
Herpes  zoster,  586 
Hip.  congenital  dislocation  of,  540 

tuberculous  disease  of,  336 
Hip-joint  disease,  336 
Hirschsprung's  disease,  206 
History  of  sick  child,  41 

blank  for,  42 
Hives,  585 

Hodgkin's  disease,  418 
Hook  worm,  216 
Hordeolum,  571,  572 
Hot-air  bath,  69 
Hot  baths,  69 
Hot  pack,  69,  70 

Hot  weather,  infant  feeding  in,  167 
Huntington's  chorea,  489 
Hutchinson's  teeth,  285 
Hydrencephalocele,  545,  546 
Hydrocele,  477 

congenital,  477 

encysted,  of  the  cord,  477 

infantile,  477 

of  tunica  vaginalis,  477 
Hydrocephalus,  526 


Hydrocephalus,  acquired,  526 

classification  of,  526 

congenital,  526 

diagnosis,  527 

etiology^  526 

prognosis,  528 

symptomatology,  526 

treatment,  528 
Hydronephrosis,  466 
Hydrotherapy,  68 
Hygiene  of  infancy,  25 
Hyperleukocytosis,  398,  401 
Hjperphonia,  501 

Hj'pertrophy  of  pylorus,  congenital,  193 
Hypodermoclysis,  73 
Hypospadias,  539 
Hypostatic  pneumonia,  370 
Hysteria,  489 

etiology,  489 

prognosis,  490 

symptomatology,  489 

treatment,  490 

Ice  cap,  68 

poultice,  69 
Icterus  in  premature  infants,  5 

neonatorum,  18 
Ichthyosis,  575 
Idiocy,  529 

etiology,  529 
prognosis,  530 
S3'mptomatology,  529 
treatment,  531 
Idiocy  amaurotic  family,  533 

Mongolian,  531 
Imbecility,  529,  and  see  Idiocy 
Immunization,  reaction  of,  77 
Impetigo  contagiosa,  578 
Inability  to  walk,  87 
Incontinence  of  urine,  468 
Incubator,  for  premature  infants,  2,  5 
Indican,  test  for,  53 
Indicanuria,  454 
Indigestion,  gastric,  acute,  190 

gastro-intestinal,  chronic,  204 
Infancy,  assimilation  in,  135 

bathing  in,  26 

clothing  in,  25 

exercise  and  fresh  airjn,'26 

general  habits  in,  27 

habits  of  sleep  in,  27 

hygiene  of,  25 

pulse  in,  45 

regularity  of  bowels,  in,  27 

respirations  in,  41 

signs  of  illness  in,  57 

urine  in,  445 
Infant,  and  see  Newly-born 

a  mammary  fetus,  91 

acutely  ill,  food  for,  156 

adaptation  of  food  to,  152 

appendix  of,  34 

attitude  of  normal.  29 


600 


INDEX. 


Infant,  auscultation  of,  47 
bladder  of,  34 

dead-born,  13  .      * 

development  of,  30 
difference    of,     in     digestive     and 

assimilative  efficiency,  135 
glands  of,  33 
growth  of,  29 
head  of,  30 
healthy,  food  for,  147 
intestines  of,  34 
lacrimal  glands  of,  33 
length  of,  29 
liver  of,  34 
loss    of     weight    during    first    few 

days,  28 
mensuration  of,  48 
muscles  of,  34 
nutrition  of,  89,  98 
of  feeble  constitution,  foods  for,  155 
pancreas  of,  33 
percussion  of,  47 

premature,  see  Premature  infants, 
previously  badly  fed,  food  for,  153 
rectal  examination  of,  48 
relative  measurements  of,  31 
salivary  glands  of,  33 
sebaceous  glands  of,  34 
shape  of,  30 
skull  of,  30,  31 
spine  of,  32 
stillborn,  13 
stomach  of,  34 
teeth  of,  34 
tendency  of,  to  adapt  themselves 

to  their  food,  134 
testicles  of,  34 
thymus  of,  34 
viscera  of,  33 
weighing  of,  28,  167 
importance  of,  166 
weight  and  development  of,  28 

chart,  168 
who  fail  to  thrive  on  fresh  milk, 

foods  for,  158 
Infant-feeding,  89,  98 

among  the  poor,  170 
carbohydrates  used  in,  112 
care  of  food,  163 
of  utensils,  166 
chemical  and  biofogical  standards 

in,  97 
directions  for  mother  or  nurse,  163 
education  of  mother  necessary,  163 
fats  used  in,  112 
fundamental  errors  in,  127 
how  to  interpret  results,  166 
in  hot  weather,  167 
methods  of  modifying  milk  for,  130 
percentage  milk  mixtures  in,  136 
practical,  136 

basis  of,  136 
proteins  used  in,  111 


Infant-feeding,  scientific,  rise  and  de- 
velopment of,  126 

when  away  from  home,  169 

when  traveling,  168 
Infant-foods,  administration  of,  165 

dispensaries,  170 

proprietary,  122 

classification  of,  122 
composition  of,  123 
Infantile  atrophy,   439,   and    see    Ma- 
rasmus 

cerebral  palsies,  522 

paralysis,  2.)2 

scurvy,  437 

stridor,  congenital,  357 
Infantilism,  424 

Brissaud  type,  424 

diagnosed  from  cretinism,  426 

Lorain  type,  424 
Infection,  how  carried,  314 
Infectious  arthritides,  303 

diarrhea,  200 

diseases,   bronchopneumonia  com- 
plicating, 367 

disinfection  in,  314 

of  the  newly-born,  14 

sick-room  in,  314 
Inflammation  of  biliary  ducts,  222 

of  portal  vein,  222 
Influenza,  273 

causes,  273 

definition,  273 

diagnosis,  276 

incubation,  273 

pathology,  273 

symptomatology,  274 

treatment,  276 
Inguinal  region,  as  aid  to  diagnosis,  86 

enlargement  of,  86 

swellings  in,  differential  diagnosis 
of,  478 

tumors  of,  86 
Injuries  during  birth,  6 

to  bone,  7 

to  head,  6 

to  muscle,  7 
Insomnia,  494 
Inspection  of  sick  child,  41 
Insufflation,  direct,  in  asphyxia,  11 
Intestines,  of  infant,  34 

tumors  of,  85 
Intubation,  257 
Intussusception,  555 

diagnosis,  556 

etiology,  555 

prognosis,  556 

symptomatology,  555 

treatment,  556 
Inunctions  for  premature  infants,  5 
Inunction  test  for  tuberculosis,  55 
Invagination,  intestinal,  555 
Irritability    of    temper,    as    a    sign    of 
illness,  57 


INDEX. 


601 


Ischemic  paralysis,  Volkman's,  484 
Ischiorectal  abscess,  559 
Itch,  the,  588 
Itch-mite,  589 

Jaundice,  220,  and  see  Icterus 
Joints,  swollen,  88 

tuberculosis  of,  334 
Jugular  bulb  infection,  568 

Keratitis,  572 
Kernig's  sign,  289 

method  of  eliciting,  45,  46 
Kidney,  amyloid,  461 

congestion  of,  455 
chronic,  455 

formation  of,  449 

large  white,  461 

passive  hjrperemia  of,  455 

tumors  of,  85,  465 

waxy,  461 
Kilmer  belt  for  pertussis,  266 
Knee,  tuberculous  disease  of,  338 
Koplik's  spots,  226 

Laboratory  feeding,  160 
Lacrimal  glands  of  infant,  33 
La  Grippe,  273 
Laryngeal  stenosis,  84 

stridor,  congenital,  357 
Laryngismus  stridulus,  356 
Laryngitis,  acute,  353 

diagnosticated  from  laryngismus 
stridulus,  356 

diphtheritic,    diagnosticated    from 
acute  laryngitis,  354 

spasmodic,  353 

submucous,  354 
Larynx,  new  growths  of,  358 

papilloma  of,  358 
Lavage,  72 
Length  of  infant,  29 

premature  infant,  3 
Leptomeningitis,  acute,  518 
Leukemia,  403 

lymphatic,  404,  406 

splenomyelogenous,  404,  406 
Leukocytes,  398,  399 

number  of,  400 
Leukocytosis,  398,  401 
Leukopenia,  398,  401 
Limp,  walking  with,  87 
Lip,  hare-,  535 
Lips,  enlarged,  82 
Liver,  219 

abscess  of,  224 

amyloid,  223 

cirrhosis  of,  224 

congestion  of,  223 

diseases  of,  219 

enlarged,  85 

examination  of,  219 

fatty,  223 


Liver,  of  infant,  34 
Lobar  pneumonia,  371 
^        complications,  371 

diagnosis,  371 

etiology,  371 

pathology,  371 

physical  signs,  371 

prognosis,  372 

symptomatology,  371 

treatment,  372 
Lobular  pneumonia,  364 
Lumbar     puncture,     in     cerebrospinal 
meningitis,  289,  292 

technic  of,  52 
Lungs,  abscess  of,  378 

diseases  of,  359 

gangrene  of,  378 
Lymphadenoma,  418 
Lymphocytes,  399 
Lymphocytosis,  398,  401 

MacEwen's  sign,  289 
Macroglossia,  83 
Malaria,  305 

differential  diagnosis,  308 

etiology,  305 

pathology,  306 

prophylaxis,  308 

symptomatology,  307 

treatment,  308 
Malformations,  congenital,  535 

of  anus,  538 

of  esophagus,  538 

of  rectum,  538 
Mammary  secretions,  and  see  Milk 

comparative,  95 
Marasmus,  439 

course,  441 

diet  in,  442 

etiology,  439 

medication,  443 

pathology,  439 

prognosis,  441 

symptomatology,  440 

treatment,  441 
Mast  cells,  400 

Mastitis  of  the  newly  born,  22 
Mastoiditis,  567 
Masturbation,  476 
Measles,  225 

complications,  227 

definition,  225 

eruption,  227 

etiology,  225 

exanthem,  227 

fever,  227 

German.  230 

incubation,  226 

Koplik's  spots,  226 

pathology,  226 

prodromal  stage,  226 

prognosis,  229 

prophylaxis,  229 


602 


INDEX. 


Measles,  sequehe,  227 
treatment,  229 
variations,  227 
Measurements,  physical,  37 
relative  of  infant,  31 
of  child,  32,  33 
Meat  broths,  to  make,  157 
Megaloblast,  398,  399 
Meningeal  apoplexy,  during  birth,  9 
Meningitis,  518 

diagnosis,  519 
etiology,  518 
leptomeningitis,  518 
pachymeningitis,  518 
symptomatology,  518 
treatment,  519 
epidemic  cerebrospinal,  287 
complications,  290 
differential  diagnosis,  290 
etiology,  287 

lumbar  puncture  in,  289,  292 
pathology,  287 
prognosis,  290 
serum  treatment,  291 
symptomatology,  288 
treatment,  291 
tuberculous,  327 
Meningocele,  544.  546 
Mensuration   of  infants   and   children, 

48 
Mental  growth  of  child,  39 
Mercurial  salts,  as  disinfectants,  313 
Microblast,  398 
Microcephalus,  528 
Microcyte,  399 
Migraine,  493 
Miliaria,  585 
Miliary  tuberculosis,  acute,  326 

of  lungs,  322 
Milk,  and  see  Mammary  secretions 

and    gruel    mixtures,     percentage 

composition  of,  143 
bacteriology  of,  114 
bottled,  116 
certified,  116 
commissions,  116 
condensed,  119 
cows',  113 
crust,  578 
evaporated,  119 
fat  in,  to  decrease,  172 

to  increase,  172 
grocery,  115 
human,  normal,  94 
inspected,  116 
market,  115 

composition  of,  117 
microscopical  appearance  of,  118 
mixtures,     percentage,     in    infant 

feeding,  136 
modified,  129 

classification    of    methods    em- 
ployed, 130 


Milk,  modified  effects  of  various  meth- 
ods employed,  131 

modifier,  150 

mother's,  disagrees  with  infant,  103 
drugs  eliminated  in,  103 
insufficient,  102 

one  cow's,  113 

pasteurized,  116 

peptonized,  159 

percentages    of    fat,    in    different 
portions  of,  138 

sanitary,  116 

production  of,  115 

sterilized,  116 

top,  137 

percentage  of  food  element  in,  141 
Mitral  obstruction,  391 

regurgitation,  391 
Modified  milk,  129 

classification  of  method,  130 

effects  of  various  method,  131 

for  premature  infants,  4 
Moles,  576 
Mongolian  idiocy,  531 

diagnosticated  from  cretinism,  426, 
532 
Moral  growth  of  child,  39 
Morbilli,  225,  and  see  Measles 
Morbus  coxse,  336 
Moro  test  for  tuberculosis,  55,  324 
Mosquitoes,  305 
Motion,  disturbances  of,  87 
Mouth,  as  aid  to  diagnosis,  82 

breathing  in  nasal  obstruction,  83 

diseases  of,  181 

fissures  of,  82 

inflammation  of,  see  Stomatitis 

open,  82 

putrid  sore,  186 

ulcerations  of,  82 

white,  184 
Movements,  purposeless  involuntary,  88 
Multiple  neuritis,  503 

sclerosis,  509 
Mumps,  267 

complications,  268 

differential  diagnosis,  268 

etiology,  267 

pathology,  267 

prognosis,  268 

symptomatology,  268 

treatment,  268 
Murmurs,  hemic,  394 
Muscles,  injuries  to,  during  birth,  7 

of  infant,  34 

paralysis  of,  484 
Muscular  atrophy,  idiopathic,  512 

dystrophy,  512 
Mustard  bath,  70 
Myelitis,  507 

diagnosis,  509 

etiology,  507 

pathology,  507 


INDEX. 


603 


Myelitis,  prognosis,  509 

symptomatology,  507 

treatment,  509 
Myelocytes,  400 
Myocarditis,  388 
Myopathy,  primary,  512 

complications,  516 

differential  diagnosis,  516 

etiology,  512 

pathology,  513 

symptomatology,  514 

treatment,  516 

types  of,  512 
Myotonia  congenita,  499 
Mytonic  reaction,  of   Erb,  499 
Myxedema,  424,  and  see  Cretinism 

Nasal  obstruction,  mouth  breathing  in, 

83 
Nasopharyngeal  toilet,  the,  71 
Nauheim  baths,  artificial,  71 
Neck,  as  aid  to  diagnosis,  82 

tumors  about,  82 
Nematodes,  211 
Nephritis,  456 
acute,  456 

causes,  456 
complications,  459 
definition,  456 
diagnosis,  459 
pathology,  457 
prognosis,  459 
symptomatology,  457 
synonyms,  456 
treatment,  460 
desquamative,  456 
diffuse,  456 
exudative,  456 
glomerulo-,  456 
parenchymatous,  456 
tubular,  456 
chronic,  461 
causes,  461 
complications,  462 
definition,  461 

diagnosed  from  cretinism,  428 
diagnosis,  462 
pathology,  461 
prognosis,  463 
symptomatology,  462 
synonyms,  461 
treatment,  463 
diffuse,  461 
interstitial,  461 
parenchymatous,  461 
Nerve  paralysis,  484 
Nerves,  peripheral,  diseases  of,  503 
Nervous  diseases,  general,  482 

system,  diseases  of,  482 
Nettle-rash,  585 
Neuritis,  multiple,  503 
course,  504 
diagnosis,  503 


Neuritis,  multiple,  etiology,  503 
prognosis,  504 
symptomatology,  503 
pathology,  503 
treatment,  504 

optic,  574 
Nevi,  576 

New  growths  of  larynx,  358 
Newly-born,  and  see  Infant 

acute  infectious  diseases  of  the,  14 

conjimctivitis  of  the,  21 

dimensions  of,  31 

diseases  of  the,  14 

fatty  degeneration  of  the,  18 

hemorrhages  of,  87 

icterus  of,  18 

mastitis  of,  22 

sepsis  of  the,  14 

spontaneous  hemorrhages  in  the,  23 

tetanus  of,  20 
Night  terrors,  495 
Nipple  shield,  107 
Noma,  187 
Normoblast,  398,  399 
Nose,  bleeding  from,  87,  341 

foreign  bodies  in,  342 
Nursery,  the,  26 
Nursing,  and  see  Breast-feeding 

contraindications  for,  107 

not  possible,  107 
Nutrition,  and  see  Feeding 

difference  of  infants  in  capacity  for, 
135 

of  infant,  89,  98 

of  premature  infants,  3 
Nutritive  periods  of  life,  90 
Nystagmus,  574 

Occlusion  of  esophagus,  congenital,  189 

Ophthalmia  neonatorum,  21 

Opsonic  index,  77 

Opsonins,  76 

Optic  neuritis,  574 

Otitis,  566 

Otoscopy,  565 

Oxyuris  vermicularis,  211 

Pachymeningitis,  518 
Packs,  hot,  69,  70 
Palate,  cleft,  536 
Palpation  of  sick  child,  44 
Palpitation  of  heart,  394 
Palsies,  birth,  8 

classification  of,  523 
infantile  cerebral.  522 

classification,  523 

diagnosis,  525 

etiology,  522 

pathology,  522 

symptoms,  524 

treatment,  525 
Palsy,  Bell's,  505 
cerebral.  295 


604 


INDEX. 


Palsy,  peripheral,  295 

spinal,  295 
Paludism,  305 
Pancreas  of  infant,  33 
Papillitis,  574 
Papilloma  of  larynx,  358 
Paralysis,  87,  483 

acute  atrophic,  292 
wasting,  292 

central,  during  birth,  9 

cerebral,  483 

diphtheritic,  504 

Duchenne's,  during  birth,  8 

epidemic,  in  children,  297 

Erb's,  during  birth,  8 

essential,  of  children,  292 

facial,  505 

during  birth,  8 

general  characteristics  of  the  vari- 
ous types,  483 

in  general,  483 

infantile,  292 

ischemic,  Volkman's,  484 

muscle,  484 

nerve,  484 

postdiphtheritic,  254 

pseudo-,  484 

spinal,  484 

upper-arm,  during  birth,  8 
Paramyoclonus  multiplex,  499 
Paraphimosis,  472 
Paraplegia,  spastic,  483,  522 
Parasites,  animal,  211 

found  in  childhood,  211 
Parasitic  protozoa,  211 

skin  diseases,  588 
Parotitis,  epidemic,  267 
Pasteurized  milk,  116 
Pasteurizer,  164,  165 
Pavor  nocturnus,  495 
Pediculosis,  588 
Pediculus  capitis,  588 
Pemphigus  neonatorum,  577 
Peptonized  milk,  159 
Percentage    milk    mixtures,    in    infant 

feeding,  136 
Percussion  of  infants  and  children,  47 
Pericarditis,  395 

diagnosis,  396 

etiology,  395 

pathology,  395 

physical  signs,  395 

prognosis,  39*6 

symptomatology,  395 

treatment,  396 
Pericardium,  diseases  of,  395 
Perinephritis,  465 
Peripheral  nerves,  diseases  of,  503 
Peritonitis,  acute,  556 
diagnosis,  558 
in  early  life,  557 
in  the  new-born,  556 
prognosis,  558 


Peritonitis, symptomatology,  557 
treatment,  559 

gonorrheal,  558 

pneumococcic,  558 

tuberculous,  330 
Peritonsillar  abscess,  352 
Perleche,  184 
Pertussis,  263 

aerotherapy  in,  265 

complications,  264 

course,  265 

diet  in,  267 

drugs  for,  265 

etiology,  263 

Kilmer  belt  for,  266 

pathology,  26i3 

primary  stage  of,  264 

prognosis,  265 

recession  of  symptoms,  264 

spasmodic  stage,  264 

symptomatology,  263 

treatment,  265 
Petit  mal,  491 
Pharyngeal  stenosis,  83 

tonsil,  hypertrophy  of,  350 
Pharyngitis,  acute,  346 

in  infants,  344 
treatment,  346 
Phimosis,  472 
Photophobia,  573 
Physical  measurements,  37 
Pioscope,  105 

Pisek's  dressing  for  umbilical  hernia,  16 
Plaques,  blood,  401 
Plates,  blood-,  401 

Platform  scale,  for  weighing  baby,  28 
Pleura,  diseases  of,  359 
Pleural  cavity,  aspiration  of,  technic  of, 

54 
Pleurisy,  372 

dry,  372 

serofibrinous,  372 
pathology,  372 
physical  signs,  373 
prognosis,  373 
symptomatology,  373 
treatment,  373 
Pneumonia,  catarrhal,  364 

croupous,     371,     and     see     Lobar 
pneumonia 

hypostatic,  370 

lobar,   371,  and   see  Lobar  pneu- 
monia 

lobular,  364 
Pneumothorax,  377 
Poikilocytosis,  398 
Poliomyelitis,  anterior,  292 

causes,  292 

definition,  292 

diagnosis,  295 

pathology,  293 

prognosis,  296 

symptomatology,  293 


INDEX. 


605 


Poliomyelitis,  treatment,  296 
Polynuclears,  399 
Polynucleosis,  398 
Polypus,  rectal,  560 
Polyuria,  451 

Portal  vein,  inflammation  of,  222 
Postdiphtheritic  paralysis,  254 
Pott's  disease,  335 

cervical,  335 

dorsal,  335 

lumbar,  335,  337 
Poultice,  ice,  69 
Practical  feeding,  136 

basis  of,  136 
Premature  infants,  breast  milk  for,  3 

care  of,  1 

cyanosis  in,  5 

danger  of  gavage  in,  4 

death  rate  of,  1 

factors  prejudicial  to  life  of,  1 

feeders  for,  4 

feeding  of.  3,  4 

icterus  in,  5 

incubators  for,  2,  5 

inunctions  for,  5 

length  of,  3 

management  and  care  of,    1 

modified  milk  for,  4 

nutrition  of,  3 

subnormal  temperature  of,  1,  2 

temperature  of,  1,  2 

weight  of,  3,  4 
Prickly  heat,  ,585 
Primary  myopathy,  512 
Prolapse  of  anus,  561 

of  rectum,  561 
Proprietary  infant  foods,  122 

classification  of,  122 

composition  of,  123 
Proteins,    forms    of,     used    in     infant 

feeding.  111 
Protozoa,  parasitic,  211 
Pseudodysphagia,  83 
Pseudoleukemia,  418 

of  infants,  405,  406 
Pseudo-paralysis,  87,  484 
Psoriasis,  584 
Psychotherapy,  66 
Ptosis,  573 
Pulmonary  abscess,  378 

collapse,  361 

tuberculosis,  324 
Pulse,  in  infancy  and  childhood,  45 
Purpura,  409 

fulminans,  411 

hemorrhagica,  410 

Henoch's,  411 

Schonlein'/s,  411 

simplex,  409 
Putrid  sore  mouth,  186 
Pyelitis,  463 

causes,  463 

definition,  463 


Pyelitis,  diagnosis,  464 

pathology,  463 

prognosis,  464 
■  symptomatology,  464 

thread  reaction  in,  55 

treatment,  464 
Pylephlebitis,  suppurative,  222 
Pyloric  spasm,  193 
Pylorus,  hypertrophy  of,  congenital,  193 

stenosis  of,  193 

Quinsy  sore  throat,  352 

Rachitic  spine,  336 
Rachitis,  431 

antenatal,  437 

congenital.  437 

course,  435 

diagnosis,  435 

deformities  in,  434,  436 

dietetic  treatment  of,  436 

etiology,  431 

hygienic  treatment  of,  436 

medication  in,  436 

pathology  of,  431 

prognosis  of,  435 

symptomatology  of,  432 

treatment  of,  435 
Reaction  of  immunization,  77 
Rectal     examination    of    infants    and 
children,  48 

feeding,  76 

polypus,  560 

syringe  for  infants,  209 
Rectum,  hemorrhages  from,  87 

malformations  of,  538 

obstruction  of,  538 

prolapse  of,  561 
Renal  calculi,  452 
Resistant  exercises,  79 
Respiratory     capacity,     exercises     for 
increasing,  79 

tract,  foreign  bodies  in,  380 
upper,  diseases  of  the,  341 
Respiration,  artificial,  methods  of,  12 

in  infancy  and  childhood,  41 
Restless  sleep,  as  a  sign  of  illness,  58 
Retropharyngeal  abscess,  352 
Rheumatic  fever,  299 
Rheumatism,  acute  articular,  299 

complications,  300 

differential  diagnosis,  301 

etiology,  299 

drugs  for,  302 

prognosis,  301 

prophylaxis,  302 

symptomatology,  300 

treatment,  302 
Rheumatoids,  304 
Rhinitis,  acute.  341 
Rickets,  431,  and  see  Rachitis 

diagnosed  from  cretinism,  428 
Rigid  extremities,  87 


606 


INDEX. 


Ringworm  of  scalp,  589 

of  tongue,  181 
Ritter's  disease,  577 
Rotheln,  230 
Round  worm,  212 
Rubella,  scarlatiniform,  diagnosticated 

from  scarlet  fever,  237 
Rubeola,  225,  230,  and  see  Measles 


Salivary  glands  of  infant,  33 

Sarcoma,  562 

Salt-rheum,  580 

Scabies,  588 

Scalp,  ringworm  of,  589 

Scarlatina,  231  and  see  Scarlet  fever 

Scarlet  fever,  231 

anginal  form,  232 

complications  of,  240 

desquamation,  232,  234 

desquamative  stage,  238 

diet  in,  239 

differential  diagnosis,  235 

eruptive  stage,  238 

etiology,  231 

incubation,  231 

pathology,  231 

predesquamative  stage,  238 

preemptive  stage  of,  238 

prognosis,  238 

prophylaxis,  239 

rash,  233 

sequelae  of,  240 

serum  treatment  of,  241 

sick-room  quarantine,  239 

simple  form,  231 

symptomatic  treatment,  240. 

symptomatology,  231 

treatment,  239 
Schonlein's  purpura,  411 
Sclerosis,  disseminated,  509 

multiple,  509 
Scorbutus,  437 

aggravated  cases,  438 

course,  438 

dietetic  treatment  of,  439 

diagnosis  of,  438 

etiology  of,  437 

mild  cases,  437 

pathology  of,  437 

prognosis  of,  438 

prophylaxis  of,  439 

symptomatology  of,  437 

treatment  of,  439 
Scurvy,  infantile,  437 
Sebaceous  glands  of  infant,  34 
Seborrhea  capitis,  578 
Secretions,  breast,  92 
Sepsis  of  the  newly-born,  14 
Serum  rashes,   diagnosed   from  scarlet 

fever,  237 
Sheet  baths,  68 
Shingles,  586 


Sick  child,  examination  of,  41 
blank  for,  42 

history  of,  41 
blank  for,  42 

inspection  of,  41 

palpation  of,  44 

to  take  temperature  of,  43 
Sick-room,  in  infectious  diseases,  314 
Signs  of  illness  in  infancy,  57 
Sinus  thrombosis,  infective  cerebral,  568 
Skin,  diseases  of,  575 

parasitic,  588 
Skin  test  for  tuberculosis,  54 
Skull  of  infant,  30,  31 
Sleep,  amount  required,  494 

habits  of,  in  infancy,  27 

restless,  as  a  sign  of  illness,  58 
Smallpox,  241 

complications,  243 

definition,  241 

etiology,  242 

exanthem,  242 

incubation,  242 

prodromal  stage,  242 

pathology,  242 

prognosis,  244 

prophylaxis,  245 

sequelae,  243 

symptomatology,  242 

treatment,  245 

variations,  243 
Soor,  184 
Soothing  bath,  70 
Sore  mouth,  putrid,  186 
Spasm,  pyloric,  193 

vesical,  481 
Spastic  diplegia,  522 

extremities,  87 

hemiplegia,  522 

paraplegia,  483,  522 
Specialized  foods,  92 
Speculum,  ear,  565,  566 
Spina  bifida,  547 
Spinal  cord,  diseases  of,  507 

inflammation  of,  see  Myelitis 
Spinal  paralysis,  484 
Spine,  caries  of,  335 

of  infants,  32 

rachitic,  336 
Spleen,  chronic  passive  congestion  of, 
417 

diseases  of,  417 

enlarged,  85 

enlargement  of,  417 

inflammation  of,  417 
Spondylitis,  335 
Sponge  baths,  68 

Spontaneous  hemorrhages  in  the  newly- 
born,  23 
Sprue,  184 

Sputum,  examination  of,  51 
Squint,  572 
Stammering,  501 


INDEX. 


607 


status  lymphaticus,  416 
Steam,  as  a  disinfectant,  313 
Stenosis,  bronchial,  84 

laryngeal,  84 

of  pylorus,  193 

pharyngeal,  83 

tracheal,  84 
Sterilized  milk,  116 
Sterilizer,  for  infant  food,  165 
Sternocleidomastoid,  hematoma  of,  7 
Stillborn  infant,  13 
Still's  disease,  305 
Stomacace,  186 
Stomach,  dilatation  of,  192 

hemorrhages  from,  87 

inflammation  of,  see  Gastritis 

of  different  milk  secreting  animals, 
96 

of  infant,  34 

tumors  of,  85 

washing,  72 
Stomatitis,  aphthous,  183 

catarrhal,  182 

follicular,  183 

gangrenous,  187 

herpetic,  183 

maculo-fibrinous,  183 

mycotic,  184 

parasitic,  184 

simple,  182 

ulcerative,  186 

vesicular,  183 
Stools,  196 

character  of,  as   a  sign  of  illness, 
59 

examination  of,  166,  197 

of  artificially  fed  infants,  197 
Strabismus,  572,  574 
Stridor,  congenital  infantile,  357 

laryngeal,  357 
Strophulus.  585 
Stuttering,  501 

St.  Vitus'  dance,  486,  and  see  Chorea 
Stye,  572 

Subdural  puncture,  technic  of,  52 
Subphrenic  abscess,  381 
Substitute  feeding,  110 

difficulties  of,  110 

material  used  in,  113 

principles  of,  110 
Suggestion,  in  treatment  of  disease,  66 
Sulphurous  acid,  as  a  disinfectant,  313 
Summer  complaint,  200 

diarrhea,  200 
Surgical  diseases,  549 
Swallowing,  as  aid  to  diagnosis,  83 
Swellings  in  inguinal  region,  differential 
diagnosis  of,  478 

of  extremities,  88 
Sydenham's  chorea,  486 
Syndactylism,  544 
Syphilis,  277 

acquired   286 


Syphilis,  cause,  277 

congenital,  277,  and  see^Syphilis, 

hereditary 
definition,  277 
hereditary,  277 
CoUes'  law,  278 
definition,  277 
diagnosis,  282 

method  of  transmission,  277 
pathology,  278 
prognosis,  284 
symptomatology,  279 
treatment,  284 
late  hereditary,  284 

Hutchinson's  teeth,  285 
treatment,  286 
Wasserman  test  for,  56 
Syringe,  rectal,  for  infants,  209 


Talipes,  541 

acquired,  542 

calcaneus,  543 

congenital,  541 

equinus,  542 

treatment,  543 

valgus,  543 

varus,  542 
Tape  worms,  214 

armed,  215 

beef,  215  . 

pork,  215 
Teeth,  abnormalities  of,  83 

of  infant,  34 

temporary,  care  of,  36 

permanent,  36 

Hutchinson's,  36,  285 
Temper,    irritability   of,    as   a   sign   of 

illness,  57 
Temperature  of  premature  infant,  1 

to  take,  43 
Tenia  mediocanellata,  214,  215 

saginata,  214,  215 

solium,  214,  215 
Testicle,  undescended,  477 
Testicles  of  infant,  34 
Tetanilla,  496,  and  see  Tetany 
Tetanus  neonatorum,  20 
Tetany,  496 

differential  diagnosis,  498 

etiology,  496 

prognosis,  498 

symptomatology,  496 

treatment,  498 
Tetter,  580 

Therapeutics,  general,  60 
Thomson's  disease,  499 
Thoracic  tuberculosis,  321 
Thoracentesis,  375 
Thread  reaction  in  pyelitis,  55 
Thread  worms,  211 

Throat,  examination  of,  in  infants,  343, 
345 


608  INDEX. 

Thrombosis,  sinus,  infective  cerebral,  568      Tuberculosis,  tests  for,  eye  test,  54 

Thrush,  184  inunction  test,  55 

Thymic  asthma,  357  •      Moro  test,  55 

Thymus,  414  skin  test,  54 

enlargement  of,  414  von  Pirquet  test,  54 

of  infant,  34  thoracic,  321 

Tics,  500  diagnosis,  322 

differential  diagnosis,  501  pulmonary  lesions,  322 

treatment,  501  treatment  in  general,  338,  339 

Tinea  favosa,  590  tuberculin  test  in,  323 
tonsurans,  589                                           Tuberculous  adenitis,  318 

Toes,  webbed,  544  course,  320 

Tongue  depressors,  Chapin's,  343  diagnosis,  320 

enlarged,  82  prognosis,  320 

fissures  of,  82  symptomatology,  318 

geographic,  181  treatment,  320 

inflammation  of,  see  Glossitis  arthritis,  305 

ringworm  of,  18i  bronchopneumonia,  322 

ulcers  of,  82  disease  of  hip,  336 

Tongue-tie,  535  treatment,  337 

Tonsillar  hypertrophy,  chronic,  349  knee,  338 

Tonsil,  pharyngeal,  hypertrophy  of,  350  treatment,  330 

Tonsillitis,  acute  follicular,  347  meningitis,  327 

in  infants,  344  course,  330 

treatment,  346  diagnosis,  330 

ulcero-membranous,  348  etiology,  328 

Top  milk,  137  prognosis,  330 

Tracheal  stenosis,  84  symptomatology,  328 

Trachoma,  571  peritonitis,  330 

Transudates,  examination  of,  53  caseating  form,  331 

Traveling,  infant  feeding  when,  168  diagnosis,  332 

Tracheotomy,  262  fibrous  form,  331 

Trichina  spiralis,  217  miliary  form,  331 

Tricuspid  regurgitation,  393  symptomatology,  332 

Trousseau's  symptom,  in  tetany,  498  treatment,  334 

Tuberculin  test,  54,  323  ulcerative  form,  331 
Tuberculosis,  316                                              Tumors  about  head,  81 

acute  miliary,  326  about  neck,  82 

differential  diagnosis,  327  •       malignant,  in  children,  562 

etiology,  326  diagnosis,  563 

bone,  334  treatment,  564 

and  joint  tuberculosis,  334  of  abdomen,  localized,  85 

diagnosed  from  syphilis,  282  of  abdominal  wall,  86 

disease  of  hip,  336  of  brain,  521 

of  knee,  338  of  chest  wall,  84 

etiology,  316  of  inguinal  region,  86 

joint.  334  of  intestines,  85 

miliary,  of  lungs,  322  of  kidney,  85,  465 

of  vertebrse,  335  of  stomach,  85 
diagnosis,  335                                        Typhoid  fever,  269 

treatment,  336  drugs  in,  273 

prophylaxis,  338  etiology  of,  269 

pulmonary,  324  feeding  in,  272 

acute  form,  324  hydrotherapy  in,  272 

etiology,  324  laboratory  tests  for,  271 

physical  signs,  325  pathology,  269 

chronic,  325  prophylaxis, 271 

causes,  326  symptomatology,  270 

subacute  form,  324  temperature  curve  in,  270 

etiology,  324  treatment,  271,  272 
physical  signs,  325 
tests  for,  54                                                Ulcerations  of  mouth,  82 

Calmette  test,  54  of  tongue,  82 


INDEX. 


609 


Umbilical  hemorrhages,  15 

hernia,  17 

Pisek's  dressing  for,  16 

region,  abnormalities  of,  86 

vegetations,  16 
Uncinaria  duodenalis,  216 
Undescended  testicle,  477 
Upper-arm  paralysis,  during  birth,  8 
Urethritis,  473 
Urine,  acetone  in,  455 

albumin  in,  454,  and  see  Albumin- 
uria 

blood  in,  453 

character  of,  446 

as  a  sign  of  illness,  59 

diacetic  acid  in,  455 

excess  of,  451 

hemoglobin  in,  453 

incontinence  of,  468 

indican  in,  454 

in  infancy,  445 

suppression  of,  450,  and  see  Anuria 

to  collect.  445 
Urinal,  for  infants,  445 
Urogenital  blennorrhea,  474 
Uropoietic  system,  diseases  of,  445 
Urticaria,  585 
Uvula,  elongated,  188 

Vaccination,  245 

description  of  normal  course,  246 

method  of,  246 

value  of,  245 

variations  and  complications,  247 

when  to  vaccinate,  246 
Vaccine  therapy,  76,  77 
Vaccinia,  245 

Valves  of  heart,  location  of,  390 
Valvular  disease  of  heart,  chronic,  389 

aortic,  392 

mitral,  391 

tricuspid,  393 
Varicella,  247 

Variola,  241,  and  see  Smallpox 
Varioloid,  243 
Vegetations,  umbilical,  16 
Vertebrae,  tuberculosis  of,  335 


Vesical  calculus,  481 

spasm,  481 
Vincent's  angina,  348 
Viscera  of  infant,  33 
Vomiting,  as  a  sign  of  illness,  58 

cyclic,  195 

periodic,  195 

recurrent,  195 
Volkman's  ischemic  paralysis,  484 
Von  Jaksch  Anemia,  405,  406 
Von  Pirquet  test  for  tuberculosis,  54, 324 
Vulvo-vaginitis,  474 

treatment,  475 

vaccine  treatment,  475 

Walk,  inability  to,  87 

with  limp,  87 
Warm  baths,  69 
Wasserman  test  for  syphilis,  56 
Wasting  paralysis,  acute,  292 
Water,  in  treatment  of  disease,  68 
Weaning  and  mixed  feeding,  107 
Webbed  fingers,  544 

toes,  544 
Weighing  infant,  28,  167 

importance  of,  166 
Weight  of  child,  38 
of  infant,  28 
of  premature  infant,  3,  4 

chart,  49 

for  infant,  168 
Wet-nurse,  selection  of,  108 
Whey,  directions  for  making,  154 

and  cream  mixtures,  154 
White  mouth,  184 

swelling,  338 
Whooping-cough,  263 
Winckel's  disease,  17 
Worms,  hook,  216 

round,  212 

tape,  214 

thread,  211 

Xerodermia,  575 
X-rayS;  use  of,  51 

Zoster,  586 


39 


Date  Due 

cwr 

CAT.    NO.    23   2 

33                          PRINT 

ED    IN    U.S.A. 

UC  SOUTHERN  REGIONAL  UBfiAHY  FAOUTY 


A  000  432  588  2 


WS200 
Ch63A 
^^^pln,  Henry  r^.   ^^   ^^09 

diseases  ^f^^«^*- 
ren.      °^  infants  and  chij 

Date 


WS200 
CU63d 
1909 
Chapin,  Henry  Dwight. 

Diseases  of  infemts  and  children 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


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